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A  TREATISE   ON   THE  DISEASES  OF   THE 
NERVOUS   SYSTEM. 


A   TREATISE 


THE    DISEASES 


NEEYOFS    SYSTE 


JAMES  EOSS,   M.D.,   LL.D., 

FELLOW  OF  THE  ROYAL  COLLEGE   OF   PHYSICIANS,   LONDON; 

SENIOR  ASSISTANT  PHYSICIAN   TO   THE  MANCHESTER   ROYAL   INFIRMARY 

CONSULTING   PHYSICIAN  TO  THE  MANCHESTER 

SOUTHERN  HOSPITAL. 


ILLUSTRATED    WITH  LITHOGRAPHS,   PHOTOGRAPHS,   AND 
THREE  HUNDRED  AND   THIRTY   WOODCUTS. 


giwontr  «J5&itioii.  Hcbtseif  anii  iiBnlargeti. 


Volume  I. 


NEW    YORK : 
WILLIAM    WOOD    AND    COMPANY. 

1883. 


MANCHESTEE  I 

PRINTED  BY  ALEXANDER  IRELAND  AND  CO., 

PALL  MALL. 


PREFACE  TO   THE   SECOND   EDITION. 


In  preparing  a  new  edition  of  this  work  I  have  endeavoured 
to  make  it  worthy  of  the  approbation  and  confidence  of  the 
profession,  A  comparison  of  the  present  with  the  first  edition 
will  show  that  the  chief  difference  between  them  consists  in  the 
insertion  of  copious  references,  an  addition  which,  I  doubt  not, 
will  be  acceptable  to  special  workers  in  the  field  of  neurology. 

But  although  the  addition  of  definite  references  constitutes 
the  main  alteration,  yet  it  is  by  no  means  the  only  one.  Every 
page,  I  may  almost  say  every  line,  has  been  subjected  to  careful 
revision,  and — I  say  it  not  without  some  regret — much  new 
matter  has  been  added.  The  additions  consist  chiefly  of  records 
of,  and  immediate  inferences  from,  observed  facts,  which  must 
necessarily  possess  more  or  less  permanent  value,  and  only 
rarely  of  opinions,  which,  except  when  they  take  the  form  of 
comprehensive  generalisations,  are  of  more  fleeting  importance. 

No  one  can  be  more  alive  to  the  imperfections  of  the  work 
than  I  am  myself,  but  whatever  may  be  its  shortcomings  I 
trust  it  will  be  accepted  as  an  earnest  attempt  to  reduce  to 
order  and  to  unify  the  multitudinous  facts  of  a  wide  and  com- 
plicated subject. 

My  thanks  are  due  to  Mr,  Wilson,  one  of  the  House  Phy- 
sicians to  the  Royal  Infirmary,  for  having  carefully  revised  the 
index. 

JAMES   ROSS. 


Manchester, 

July  5th,  1883. 


PREFACE    TO    FIRST    EDITION. 


In  the  following  pages  I  have  endeavoured  to  give  a  tolerably 
full  account  of  the  diseases  to  which  the  nervous  system  is 
liable,  with  the  exception  of  the  psychoses,  which  form  a 
sufficiently  large  and  important  group  to  demand  a  separate 
treatise.  It  would  be  invidious  to  single  out  for  special  men- 
tion a  few  of  the  many  authors  whose  works  I  have  had 
occasion  to  consult;  I  must,  therefore,  ask  them  all  to  accept 
the  simple  acknowledgment  conveyed  in  the  insertion  of  their 
names  in  the  text. 

A  large  number  of  the  illustrations  are  borrowed  from  Henle's 
"  Anatomie,"  Landois'  "  Physiologie,"  Heath's  "  Anatomy," 
Tibbits'  "Medical  Electricity,"  Walton  "On  Diseases  of  the 
Eye,"  and  Gamgee's  translation  of  Hermann's  "Physiology," 
as  well  as  from  the  writings  of  Flechsig,  Duchenne,  Charcot, 
Erb,  and  several  other  authors.  A  considerable  number,  how- 
ever, are  original,  most  of  these  being  drawings  taken  by  Dr. 
A.  H.  Young  from  my  own  sections. 

I  have  to  express  my  obligations  to  several  of  my  colleagues 
at  the  Manchester  Royal  Infirmary  for  the  kindness  and 
courtesy  with  which  they  have  placed  cases  at  my  disposal, 
and  for  much  valuable  aid  during  the  progress  of  the  work 
through  the  press. 

In  common  with  all  other  medical  workers  in  Manchester, 
I  owe  to  Mr.  T.  Windsor  a  debt  of  gratitude  which  can  never 
be  repaid  ;  inasmuch  as,  with  but  a  small  annual  sum  at  his 
disposal  for  the  purchase  of  books,  he  has,  with  singular  energy 
and  life-long  devotion,  placed  within  reach  of  the  profession  one 
of  the  best  medical  libraries  of  reference  in  the  kingdom. 

I  have  already  mentioned  the  name  of  Dr.  A.  H.  Young, 
Pathological  Registrar  to  the  Manchester  Royal  Infirmary ;  my 


VI  PKEFACE   TO   FIKST   EDITION. 

thanks  are  due  to  him  in  a  special  manner  not  only  for  his 
excellent  drawings,  but  also  for  much  valuable  assistance  in 
preparing  the  anatomical  part  of  the  work,  and  the  sections  on 
shock  and  concussion. 

I  am  indebted  to  Dr.  Lindemann  for  preparing  a  copious 
index,  upon  which  he  has  expended  great  care  and  labour. 

M)''  chief  thanks,  hovvever,  are  due  to  Dr.  Steell,  Resident 
Medical  Officer  of  the  Manchester  Royal  Infirmary,  and  I  do 
not  know  how  to  express  them  adequately  without  appearing 
to  involve  him  in  a  joint  responsibility  not  only  for  what  there 
is  of  merit  in  the  work  but  for  its  many  shortcomings  also. 
He  has  carefully  assisted  me  in  correcting  all  the  proof-sheets, 
and  has  in  doing  this  subjected  the  entire  text  to  the  whole- 
some ordeal  of  a  severe  criticism,  whereby  the  work  has  gained 
largely  both  in  accuracy  of  statement  and  conciseness  of  style. 

It  was  my  intention  to  have  supplied  a  copious  bibliography, 
but  the  unexpected  size  which  the  work  has  attained  com- 
pelled me  to  abandon  this  idea,  I  have  had  to  content  myself 
with  giving  a  few  general  instructions  to  the  reader,  which  will, 
I  trust,  enable  him  to  find  without  much  difficulty  the  works 
and  papers  to  which  reference^  is  made  in  the  text. 


^6,  King  Street, 

Manchester, 

JUwch  6J/t,  ISSJ^ 


CONTENTS    OF    VOLUME    I. 


BOOK    I. 
GENEKAL    PATHOLOGY   OF   THE    NERVOUS    SYSTEM. 

PAGE. 

Chapter    I.    Introduction — The  Structure  and  Functions  of 

THE  Nervous  System 3 

Chapter   II.  General  Etiology 73 

Chapter  III.  General  Symptomatology. 

General  Classification  of  Elementary  Symptoms    ...       79 

Chapter  IV.  Elementary  Affections   op   Individual   Sensory 
Mechanisms  (^sthesioneuroses). 

(l.)  Cutaneous  jEsthesioneuroses  106 

(li.)  Muscular  iEsthesioneuroses       ...         ...         ...         ...  124 

(in.)  Articular  and  Osseous  ^sthesioneuroses 126 

(iv.)  Visceral  jEsthesioneuroses  ...         ...         ...         ...  128 

Chapter   V.    Elementary    Affections    of    Individual    Motor 
Mechanisms  (Kinesioneuroses). 

(l)  External  Kinesioneuroses     ...     134 

(il)  Visceral  Kinesioneuroses  ...         ...         ...         ...  201 

(ill.)  Vascular  Kinesioneuroses,  or  Angioneuroses        ...         ...     214 

Chapter  VI.  Trophoneuroses. 

(i.)  Trophic  Affections  of  the  Nervous  System 226 

(n.)  Muscular  Trophoneuroses ...  ...     234 

(ill.)  Cutaneous  Trophoneuroses         ...         ...         ...         ...  242 

(iv.)  Articular  and  Osseous  Trophoneuroses      ...         ...  ...     267 

(v.)  Nutritive    and    Secretory   Affections   of    the    Glandular 

Apparatus       274 

(vl)  Visceral  Trophoneuroses       ...     279 


Vlll  TABLE  OF   CONTENTS. 

fAGE. 

Chapter  VI  I.  General  Morbid  Anatomy  and  Physiology. 

(i.)  Classification  according  to  the  Nature  of  tiie  Lesion       ...     281 
(n.)  Classification  according  to  the  Form  of  the  Lesion    ...  282 

(ill.)  Classification  according  to  the  Alterations  of  Function 

produced  by  the  Lesion 284 

Chapter  VIII.  General  Diagnosis  and  Prognosis. 

(l)  Diagnosis 288 

(ii.)  Prognosis         ...         ...         294 

Chapter  IX.     General  Treatment        298 


BOOK    II. 

SPECIAL    PATHOLOGY    OF    THE    NERVOUS    SYSTEM. 

Part  I. 
DISEASES    OF   THE    PERIPHERAL    NERVES, 

Chapter    I.  Anatomical  Introduction       333 

Chapter  II.  General  Diseases  of  the  Peripheral  Nerves. 

(l)  Hypersemia  of  the  Nerves  346 

(il)  Neuritis  and  Atrophy  346 

(in.)  Hypertrophy  and  Neoplastic  Formations        360 

Chapter  III.  Diseases  of  the  Nerves  of  Special  Sense. 

(l  )  Diseases  of  the  Olfactory  Nerves     ...         ...         ...         ...  365 

(n.)  Diseases  of  the  Sense  of  Sight 371 

(hi.)  Diseases  of  the  Acoustic  Nerves      404 

(iv.)  Diseases  of  the  Gustatory  Nerves         ...         ...         ...  415 

Chapter  IV.  Diseases  of  the  Motor  Cranial  Nerves  (Ocular, 
Facial,  and  Hypoglossal  Nerves). 

(l)  Diseases  of  the  Ocular  Motor  Nerves         425 

(n.)  Diseases  of  the  Facial  Nerve     463 

(iil)  Diseases  of  the  Hypoglossal  Nerve  485 

Chapter  V.  Diseases  op  the  Mixed  Cranial  Nerves  (Trgie- 
minus,    and    the  Pneumogastric    with   the    Spinal 
Accessory), 
(i.)  Diseases  of  the  Trigeminal  Nerve  ...         ...         ...     491 

(ii.)  Diseases  of  the  Pneumogastric  Nerve  ...         ...  514 

(in.)  Diseases  of  the  Spinal  Accessory  Nerve 554 


TABLE  OF   CONTENTS.  IX 

PAGE. 

Chapter    VI.    Diseases     of     the     Cervical     and     Brachial 
Plexuses, 
(l)  Diseases  of  the  Cervical  Plexus       ...         ...         ...         ...     566 

(n.)  Diseases  of  the  Brachial  Plexus  576 

Chapter  VII.   Diseases  of  the  Dorsal  Nerves  and  Lumbar 
Plexus. 

(i.)  Diseases  of  the  Dorsal  Nerves  ...         ...         ...         ...     636 

(ii.)  Diseases  of  the  Lumbar  Plexus  642 

Chapter  VIII.  Diseases  of  the  Sacral  and  Coccygeal  Nerves.    652 

Part  II. 
DISEASES  OF  THE  SYMPATHETIC  SYSTEM. 

Chapter  I.    Summary  op  the  Functions  of  the   Sympathetic 

System 677 

Chapter  II.  Diseases  op  the  Cervical   Portion  op  the  Sym- 
pathetic. 
(i.)  Organic  Affections  of  the  Cervical  Portion  of  the  Sym- 
pathetic     ...         ...         ...         ...         ...         ...         ...     683 

(ii.)  Functional   Affections   of  the    Cervical    Portion    of  the 
Sympathetic. 

(1)  Cephalalgia — Hemicrania  '      ...         ...         ...     689 

(2)  Graves' Disease  (Exophthalmic  Goitre)    ...  709 

(3)  Unilateral  Progressive  Atrophy  of  the  Face  . .     720 

Chapter  III.  Diseases  of  the  Thoracic  Portion  op  the  Sym- 
pathetic— Angina  Pectoris  727 

Chapter    IV.    Diseases    of  the    Abdominal    Portion    of   the 
Sympathetic. 

(i.)  Neuroses  of  the  Cosliac  Plexus       ...         ...         ...         ...  736 

(ii.)  Neuroses  of  the  Gastric  Plexus  ...         ...         ...  739 

(ill.)  Neuroses  of  the  Hepatic  Plexus     ...         ...         ...         ...  741 

(iv.)  Neuroses  of  the  Hypogastric  Plexus 742 

Part  III. 

DISEASES  OF  THE  SriNAL  CORD    AND   MEDULLA 
OBLONGATA. 

Chapter     I.  Anatomical  and  Physiological  Introduction     ...     747 


X  TABLE   OF   CONTENTS. 

PAGB. 

Chapter  II.  Morbid  ANATOinr  and  CLASSiriCATiOiSf  of  the 
Diseases  op  the  Spinal  Cord  and  Medulla 
Oblongata 

(l)  Morbid  Anatomy 839 

(n.)  Classification 858 

Chapter  III.    System     Diseases    op    the    Spinal    Cord    and 
Medulla  Oblongata. 
(i.)  Poliomyelopathies. 

(1)  Poliomyelitis  anterior  acuta  863 

(2)  Paralysis  ascendens  acuta        899 

(3)  Poliomyelitis  anterior  chronica     912 

(4)  Periependymal  myelitis  929 

(5)  Progressive  muscular  atrophy       ...         ...  937 

(6)  Primary  labio-glosso-laryngeal  pai'alysis       . . .  968 

(7)  Ophthalmoplegia  externa 983 

(8)  Pseudo-hypertrophic  paralysis  991 


DESCRIPTION  OF  PLATES. 


PAGE. 

PLA.TE  I ...     ...  (Walton)    Vol,  I.     ...    392 

1.  Normal  Optic  Disc. 

2.  Optic  Neuritis, 

3.  White  Atrophy. 

4.  Grey  Atrophy. 

PLATE  II.      Photographs  by  Mudd    Vol.   I,     ...    942 

1,  2,  and  3.  Hand  in  Progressive  Muscular  Atrophy  (Main  en  Gh-iffeJ. 

4  and  6.  Progressive  Muscular  Atrophy,  showing  atrophy  of  the 
Rhomboid  Muscles. 

5.  Infantile  Paralysis. 

PLATE  III.    Photographs  by  Mudd    Vol,   I.     ...    996 

1,  2,  3,  and  4.  Different  Attitudes  in  cases  of  Paeudo-hypertrophic  Paralysis. 

PLATE  IV.     Photographs  by  Mudd   Vol.  II.     ...      34 

1  and  2.  Arthropathies  of  Locomotor  Ataxy, 
3  and  4.  Paralysis  Agitans. 

PLATE  V.      Illustrating  the  Morbid  Anatomy  of  Tetanus 

and  Hydrophobia Vol,  II,     ...    824 

PLATE  VI.    Photographs  by  Mudd    Vol,  II.     ...    440 

1.  Hemiplegia  with  subsequent  Contracture. 

2,  3,  and  4.  Spastic  Hemiplegia  of  Childhood. 


DESCRIPTION   OF  ILLUSTRATIONS. 


Fig. 
1. 
2. 
3. 

4. 

5. 
6. 

7. 


9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 
27. 
28. 
29. 
30. 
31. 

32. 
33. 

34. 

35. 


VOLUME    I. 

Ganglion  Cells  and  Nerve  Fibres Landois. 

Schema  of  Cerebro-spinal  System       

„  Cerebello-spinal  System     .., 

Spinal  Cord  of  Human  Embryo  at  five  months 

Section  of  the  Crura  Cerebri 

Schema  of  Encephalo-spinal  Action 

Diagram  illustrating   the  Attachments    of    some  of   the  most 

important  Muscles  which  keep  the  body  in  the  erect  posture     

Diagram    representing    the    Electrical  Keactions  of  Paralysed 

Nerves  and  Muscles — Rapid  Recovery       Erb. 

Ditto  Slow  Recovery ,, 

Ditto  No  Recovery     ,, 

Ditto  Partial  Reaction  of  Degeneration      ...  ,, 

Graphic  representation  of  the  Patellar-tendon  Reaction      ...   Watteville. 

Section  of  the  Spinal  Cord— Lumbar  Enlargement 

Schema  of  Cerebro-spinal  Action 

,,  the  Action  of  the  Cardiac  Nervous  Mechanism 

,,  the  Innervation  of  the  Bladder  and  Rectum        

Alteration  in  Nerve  Fibres  after  section    Ranvier. 

Structure  of  Muscle Landois. 

Atrophy  of  Muscular  Fibres— Infantile  Paralysis Hay  em. 


Diagram  illustrating  "  Recurrent  Sensibility  "       Young. 

Transverse  Section  of  a  Nerve      Klein. 

The  Corpora  Quadrigemina  viewed  from  above       Henle. 

Diagram  of  the  semi-decussation  of  the  Chiasma    Landois. 

Horizontal  Section  of  the  Visual  Cortical  Areas    Munk. 

Diagram  of  the  Cortical  Visual  Spheres  as  seen  from  above       ••.        ,, 

View  of  the  Posterior  Surface  of  the  Medulla  Oblongata     Erb. 

Lateral  View  of  the  Medulla  Oblongata    „ 

The  Base  of  the  Brain     Ht-nle. 

Internal  View  of  the  Base  of  the  Skull      ,, 

Horizontal  Section  of  the  Optic  Nerve  at  its  point  of  insertion 

in  the  Globe      ...     ... ...Landois. 

Point  of  entrance  of  the  Optic  Nerve  with  the  Retinal  vessels    ...      ,, 

Diagram  showing  the  Fields  of  Colour  Vision  in  a  normal  emme- 
tropic eye  on  a  dull  day Gowers. 

Diagram  of  the  Decussation  of  the  Optic  Tracts     Charcot. 

,,  ,,       Glosso-Pharyngeal  Nerve Young. 


Page. 
20 
49 
53 
55 
57 
60 

62 

150 
150 
150 
151 
167 
169 
191 
204 
211 
228 
236 
238 
239 
333 
334 
336 
337 
338 
338 
341 
342 
344 
345 

372 
373 

379 

384 
417 


XIV 


DESCRIPTION   OF  ILLUSTRATIONS. 


Pig, 
36. 

37. 

38, 
39. 
40. 
41. 

42. 
43. 
44, 
45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53, 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
6L 
62. 
63. 
64. 

65. 

66. 
07. 
68. 
69. 
70. 
71. 
72. 
73. 
74. 
75. 
76. 

77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 


Page. 

418 

Young    425 


Diagram  of  the  Ocular  Nerves,   along  witli   the    Trigeminus, 

Facial,  and  Glosso-Pharyngeal  Nerves Landois. 

,,          ,,           Ophthalmic  division  of  the  fifth,  along  with  the 
third,  fourth,  and  sixth  nerves 

I  Portraits  showing  disorders  of  the  associated  movements  of  the 

)  eyes      

Diagram  of  the  Attachments  of  the  Ocular  Muscles  and  of  their 

Axes  of  Rotation Landois, 

„  ,,       Positionof  Double  Images  in  cases  of  strabismus.  Bristow 

Transverse  Section  of  the  Crura  Cerebri    

Hutchinson's  Pupilometer     

Erb's  Diagram  of  the  Innervation  of  the  Iris ... 

Diagram  of  Facial  Nerve      Young. 


...     Heath. 

Ziemssen. 

Young. 

Hirschfeld  and  Leveill^. 
...  Flower. 


Muscles  of  the  Head  and  Face    ... 

Motor  points  of  the  Face       

Diagram  of  the  Hypoglossal  Nerve 

Nerves  of  the  Face  and  Scalp 

Sensory  Nerves  of  the  Head  and  Face 

Diagram  of  the  Second  Division  of  the  Fifth  Nerve      Young. 

sj  !)        Xljird  ,,  ,,  ,,  ,, 

„           „       Pneumogastric  and  Spinal  Accessory  Nerves    ...        ,, 
Muscles  of  the  Palate      Heath. 

„  ,,       Pharynx „ 

Styloid  Muscles  and  Muscles  of  the  Tongue    „ 

Distortion  of  the  Uvula  in  Facial  Paralysis      Sanders. 

Posterior  View  of  the  Larynx  after  removal  of  the  Muscles       ...Landois. 

Anterior  ,,  ,,  „  „  ,,  

Posterior  View  of  the  Larynx  showing  the  Muscles      „ 

The  Laryngeal  Nerves     ,, 

Schema  of  a  Horizontal  Section  through  the  Larynx    ,, 

,,       of  a  Horizontal  Section  through  the  Larynx,  showing 

the  action  of  the  Arytsenoid  Muscles      „ 

Ditto   Horizontal    Section    through    the   Larynx,    showing  the 

action  of  the  Crico-Arytsenoidei  Laterales  Muscles       ,, 

Laryngoscopic  appearances  of  the  Interior  of  the  Larynx ,, 

,,  ,,  of  Larynx  during  quiet  breathing    ...      „ 

,,  ,,  ,,  ,,       vocalisation „ 

„  ,,  ,,  ,,       deep  inspiration  ...      „ 

Spasm  of  the  Trapezius Duchenne. 

Nerves  of  the  Cervical  Plexus      Flower. 

Spasm  of  the  Splenius     Duchenne. 

Nerves  of  the  Brachial  Plexus      Flower. 

I  Cutaneous  Nerves  of  the  Trunk  and  tipper  Extremity        ,, 

Distribution  of  the  Sensory  Nerves  in  the  Back  of  the  Hand      ...  Krause. 
1  ,,  ,,  ,,       of  the  hand  on  the  Dorsal  and 

)  Palmar  Aspects         ...       Mitchell. 

e  i)  »  >»  >'  "  »> 

,,  of  Ansesthesia  after  Section  of  the  Radial  Nerve         „ 

I  ,,  ,,  in  Rupture  of  the  Brachial  Plexus 

,,  in  Section  of  the  Brachial  Plexus      Duhring. 


429 

432 

438 
442 
446 
448 
464 
465 
484 
486 
492 
500 
502 
503 
515 
518 
519 
519 
522 
528 
528 
529 
529 
530 

530 

531 
542 
543 
543 
543 
556 
568 
570 
578 

582 

.583 

585 
587 
588 
589 
590 


DESCRIPTION   OF   ILLUSTRATIONS. 


XV 


90. 
91. 

92. 

93. 

94. 

95. 

96. 

97. 

98. 

99. 

100. 

101. 

102, 

103, 

104. 

105. 

106. 

107. 
108. 

109. 

110. 

111. 

112. 

113. 

114, 

115. 

116. 

117. 

118. 

119. 

120. 

121. 

122. 

123. 

124. 

125. 

126. 

127. 

128. 

129. 

130. 

131. 
132. 


{Distribution  of  Anaesthesia  in  disease  of  the  Spinal  Cord  on  a 
level  with  the  Eighth  Cervical  and  First  and  Second  Dorsal 
Nerves 

Contraction  of  the  Rhomboid  Muscles     ... 

Muscles  of  the  Hand     

Attachment  of  Interosseous  Muscle 

Insertion  of  the  Muscles  of  the  Thumb    

Position  of  the  Hand  in  Spasm  of  the  Interosseous  Muscles 

Muscles  of  the  Back      

„  Anterior  Aspect  of  the  Trunk 

Paralysis  of  the  Serratus  Magnus      

Motor  Points  on  the  Surface  of  the  Trunk     ... 

Muscles  of  the  Anterior  Aspect  of  the  Upper  Arm      

Superficial  Muscles  of  the  Back  of  the  Forearm    ,, 

Deep  Muscles  of  the  Back  of  the  Forearm      ,, 

Superficial  Muscles  of  the  Forearm ,, 

Deep  Muscles  of  the  Forearm     ... ,, 

Main  en  Griffe Duchenne. 

Motor  Points  of  the  Anterior  Surface  of  the  Left  Arm      ...      Ziemssen. 
„  Posterior        ,,  ,,  ...  „ 

,,  Anterior  Surface  of  Left  Forearm      ...  „ 

,,  Posterior        „  „  ...  ,, 

Attitude  of  the  Hand  in  Cervical  Pachymeningitis      ...Charcot. 


Page. 


Duchenne. 
...  Heath. 
Duchenne. 

...  Gowers, 
...   Heath, 

Withers. 
Ziemssen. 
...   Heath, 


...     ...  Flower. 

Heath. 

Flower. 

Weir  Mitchell, 
Heath. 


Ziemssen. 


>  Distribution  of  Ansesthesia  in  Rupture  of  the  Brachial  Plexus ... 

Lumbar  Plexus       ...     Flower. 

Muscles  of  the  Anterior  Femoral  Region...     Heath. 

Deep  Muscles  of  the  Gluteal  Region ,, 

Muscles  of  the  Posterior  Femoral  and  Gluteal  Region        ...     ...        „ 

Sacral  and  Coccygeal  Nerves      

Second  Stage  of  Dissection  of  the  Sole  of  the  Foot 

Cutaneous  Nerves  of  the  Lower  Extremity     

Diagram  of  Foot  in  Plantar  Neuralgia    

Muscles  of  the  Front  of  the  Leg 

Superficial  Muscles  of  the  Back  of  the  Leg     

Deep  Layer  of  the  Muscles  of  the  Back  of  the  Leg 
Motor  Points  of  the  Back  of  the  Lower  Extremity 

Front  „  ...     ... 

„  Anterior  and  Internal  Aspect  of  the  Leg  ,, 

,,  External  Aspect  of  the  Leg „ 

Diagram  of  the  Sympathetic  System  of  Nerves    Flower. 

Erb's  Diagram  of  the  Innervation  of  the  Iris 

View  of  the  Base  of  the  Skull,  showing  the  Points  of  Exit  of  the 

Cranial  Nerves,  and  the  Sensory  Nerves,  to  the  Dura  Mater.    Henle. 

Unilateral  Progressive  Atrophy  of  the  Face Romberg. 

Transverse  Section  of  the  Spinal  Cord  in  the  Upper 

Dorsal  Region Key  andRetzius. 

Diagram  of  Transverse  Section  of  the  Spinal  Cord  and 

its  Membranes,  natural  size „  „ 

Arteries  of  the  Medulla  Oblongata,  Pons,  and  Inferior  Surface 

of  the  Cerebellum    Duret. 

Diagram  of  the  Arteries  of  the  Pons  and  Medulla  Oblongata  ...         „ 
Distribution  of  the  Arteries  of  the  Floor  of  the  Fourth  Ventricle         „ 

VOL.  L  .  h 


.592 
593 
595 
596 
596 
597 
608 
609 
613 
615 
617 
618 
618 
622 
623 
624 
625 
626 
628 
629 
630 

633 

644 

648 
649 
650 
654 
656 
659 
662 
669 
670 
671 
672 
673 
674 
675 
680 
685 

702 
723 

748 

749 

751 

752 
753 


XVI 


DESCRIPTION   OF  ILLUSTRATIONS, 


Page. 
754 


Young.     756 


...     ...    Dnret. 

758 

Henle, 

701 

Quain. 

762 

Henle. 

764 

5J 

765 

,, 

768 

Yotino:. 


Fig. 

133.  Arteries  of  the  Posterior  Part  of  the  MeduUa  and  the  Cerebellum    Duret 

134.  Diagram  of  the  Distribution  of  the  Blood-vessels  in  the  Spinal 

Cord     

135.  Transverse  Section  of  the  Medulla  Oblongata,  showing  the  Dis 

tribution  of  the  Vessels »     

136.  Vertical  Section  of  the  Raphe  of  the  Medulla  Oblongata 

137.  Diagram  of  the  Anterior  Surface  of  a  Spinal  Segment 

138.  Diagram  of  the  Spinal  Cord  and  its  Membranes 

139.  Deiter's  Cells    ... 

140.  Vertical  Microscopical  Section  of  the  Spinal  Cord 

141.  Section  from  the  Middle  of  the  Cervical  Enlargement  of  the 

Spinal  Cord  at  the  Third  Month  of  the  Embryonic  Life 

142.  Section  of  the  Spinal  Cord  of  a  Five-months  Human  Embryo 

and  Cervical  Enlargement     

143.  Ditto  Lumbar  Enlargement        

144.  Ditto  Nine-months  ditto  Lumbar  Enlargement     ... 

145.  Ditto  ,,  Cervical  ,, 

146.  Ditto  of  the  Adult  from  the  Middle  of  the  Lumbar  Enlargement       ,, 

147.  Ditto  „  „  Cervical  ,,  ,, 

148.  Ditto  of  a  Calf  „  „  „  '    „ 

149.  Transverse  Section  of  the  Cervical  Part  of  the  Spinal  Cord  of  a 

Human  Embryo  of  Six  Weeks     Kolliker. 

150.  Spinal  Cord  of  a  Human  Embryo  at  Five  Months       

151.  Transverse  Section  of  a  Portion  of  the  Pyramidal  Tract    ...     

152.  ,,  of  the  Spinal  Cord — Middle  of  the  Lumbar 

Enlargement ... 

153.  „  of  the  Spinal    Cord— Lower  End   of    the 

Dorsal  Region       

154.  „  „  Upper  End  of   the 

Dorsal  Region  ...     ..      ... 

155.  „  „  Middle    of  Cervical 

Enlargement    

156.  „  ,,  On  a  Level  with  the 

Second  Cervical  Nerve  ... 

157.  Section  of  the  Human  Adult  Spinal  Cord — Upper  Cervical  Region    

158.  „  ,,  Upper  Dorsal  Region      

159.  „  Lower  End  of  the  Medulla  Oblongata     Young. 

160.  Formatio  Reticularis  of  the  Medulla  Oblongata    .=.     ...    Henle. 

161.  Section  of  the  Medulla  Oblongata  on  a  Level  with  the  Glosso- 

pharyngeal Nerve    Young. 

162.  Ditto,  on  a  Level  with  the  Acoustic  Nerve    ...       Flechsig. 

163.  Section  of  the  Pons  on  a  Level  with  the  Abducens  and  Facial 

Nerves Erb. 

164.  „  ,,  on  a  Level  with  the  Trigeminus ,, 

165.  5,  ,,-         on  a  Level  with  the  Upper  End  of  the 

Fourth  Ventricle      „ 

166.  Sectionof  the  Crus  Cerebri...     Krause. 

167.  Section  of  the  Grey  Substance  of  the  Medulla  Oblongata  a  little 

below  the  Point  of  the  Calamus  Scriptorius     ...Young. 

168.  Diagram  of  the  Grey  Masses  of  the  Brain  and  Spinal  Cord, 

showing  the  Course  of  the  Conducting  Paths  ...     Flechsig. 

169.  Ditto  of  a  Transverse  Section  of  the  Spinal  Cord  in  the  Upper 

Half  of  the  Dorsal  Region „ 


771 

772 
772 
773 
773 

774 
774 
775 

779 
780 

781 

'782 

783 

784 

785 

786 
787 
787 
791 
792 

794 
796 

797 
798 

799 
800 

802 

810 

812 


DESCRIPTION    OF   ILLUSTRATIONS.  XVU 

Fig.  Page. 

170.  Diagram  of  a  Spinal   Segment  as  a  Centre  and  Conducting 

Medium      ...     ...     ...     Bramwell.    818 

171.  Section  of  the  Anterior  Pyramid  of  the  Medulla. 

Debove  and  Gombault.    819 

172.  Horizontal  Section  of  the  Anterior  Part  of  the  Median  Eaph(5 

of  the  Medulla  Oblongata      821 

173.  Diagram  of  the  Course  of  the  Principal  Conducting  Paths  of  the 

Cbrd     Erb,     828 

174.  Ganglion  Cells  of  the  Anterior  Grey  Horns  of  the  Spinal  Cord, 

normal  and  diseased Young.     840 

|y5'  (_  Transverse  Sections  of  the  Spinal  Cord — Ascending  Degenera- 

177.)       ^^'^^      "     ••• 

r^p   (Transverse  Sections  of  the  Spinal  Cord — Descending  Degenera 

180.J        tioii       •     

181.    Transverse  Section  of  the  Medulla  Oblongata— Sclerosis  of  the 

Anterior  Pyramids  ... 

loo  (  Transverse  Sections  of  the  Spinal  Cord,  showing  Descendim 
Loo, 


.84.) 


Charcot. 

845 

• 

846 

•        „ 

847 

)j 

847 

184)        Sclerosis  of  the  Pyramidal  Tract 

185.  Transverse  Section  of  the  upper  end  of  the  Conus  Medullaris 
of  the  Spinal  Cord,  from  a  case  of  Congenital  Talipes 
Equino-varus     Young.     850 

18(5.     Section  of  the  Lumbar  Region  of  the  Spinal  Cord— Infantile 

Paralysis     ,,         855 

187.  Section  of    Cervical    Enlargement  of    Spinal  Cord  —  Central 

Myelitis      „         856 

188.  Diagram  of  the  System-diseases  of  the  Spinal  Cord      Charcot.     860 

189.  Portrait — Genu  Eecurvatum  in  Infantile  Paralysis      Larmuth.    875 

190.  Muscular  Fibres,  from  a  case  of  advanced  Infantile  Paralysis  ...  Young.    882 

191.  Transverse  Section  of  the  Spinal  Cord — Infantile  Paralysis..  Humphreys.     886 

192.  „  „  „  „  ,,  „  ...Charcot.     889 

IJo.  ,,  ,,  ,,  ,,  ,,  ,,  ••■  ,,  OJjS 

194.  Section  of  the  Spinal  Cord,  Dorsal  Region — Acute  Ascending 

Paralysis     Young.    908 

195.  Section  of  the  Spinal  Cord,  Cervical  Region — Acute  Ascending 

Paralysis     ...     ,,         909 

196.  Transverse  Sections  of  the  Spinal  Cord  and  Medulla  Oblongata 

at  different  levels — Chronic  Atrophic  Spinal  Paralysis    ...  Young.    926 

197.  Section  of  Spinal  Cord  from  a  case  of  syringomyelia Leyden.    933 

198.  „  „  „  „  Gull.     933 

199.  Position  assumed  by  the  Scapulas  when  the  arms  are  extended 

forwards— Progressive    Muscular    Atrophy  with   Paralysis 

of  the  Rhomboid  Muscles       Culling  worth.    945 

200.  Shows  the  appearance  of  the  Back  when  a  healthy  subject  is 

placed  in  the  same  attitude ,,  915 

201.  Same  case  as  Fig.  199,  in  the  erect  posture  and  the  Scapulis 

brought  together      „  947 

202.  Transverse  Section  of  the  Cervical  Region  of  the  Spinal  Cord- 

Progressive  Muscular  Atrophy     Charcot.     958 

203.  Transverse  Section  of  the  Cervical  Region  of  the  Spinal  Cord- 

Progressive  Muscular  Atrophy ...  Young.    959 

204.  Transverse  Section  of  the  Spinal  Cord  from  the  middle  of  the 

Cervical  enlargement— Progressive  Muscular  Atrophy Leyden.    960 


XVm  DESCRIPTION    OF   ILLUSTRATIONS. 

I'iG.  Page. 

205.  Grey  Substance  on  the  floor  of  the  Fourth  Ventricle—Pro- 

gressive Muscular  Atrophy  and  Bulbar  Paralysis ...Leyden,    980 

206.  Muscular  Fibres  in   various   stages  of  degeneration— Pseudo- 

hypertrophic Paralysis   Young.  1013 

207.  Transverse  Section  of  the  Spinal  Cord  from  the  lower  half  of 

the  Lumbar  Enlargement— Pseudo-hypertrophic  Paralysis..        ,,        1014 

208.  Transverse  Section  from  the  same  as  Fig.  207— The  middle  of 

the  Dorsal  Region     ,,        1015 

209.  Transverse  Section  from  the  same  as  Fig.  207— The  upper  half 

of  the  Cervical  Enlargement 1016 


VOLUME    II. 

210.  Transverse  Section  of  the  lower  portion  of  the  Lumbar 

Enlargement— Locomotor  Ataxia     ...  Charcot  and  Pierret.      53 

211.  From  a  case    of  Locomotor  Ataxia,   complicated  with 

Muscular  Atrophy       ...     „  55 

212.  Attitude  of  the  Hand  and  Forearm  in  a  case  of  Amyotrophic 

Lateral  Sclerosis      ...     Charcot.      78 

213.  Transverse  Section  of   the  Medulla  Oblongata— Amyotrophic 

Lateral  Sclerosis       ,,  83 

214.  Section  of   the  Middle  of   the  Cervical  Enlargement  of  the 

Spinal  Cord  from  a  Case  of  Central  Myelitis  ...     ...     Young.     108 

215.  Arteries  of  the  Medulla  Oblongata,  Pons,  and  Inferior  Surface 

of  the  Cerebellum    ,.    Duret.     138 

216.  Section  of  the  Medulla  Oblongata,  showing  the  Position  of  the 

Lesion  in  a  Case  of  Crossed  Hemiansesthesia Senator.     139 

217.  Diagram  showing  the  Distribution  of  Aneesthesia  in  a  Case  of 

HEematomyelia 159 

218.  Portrait  of  a  Girl  the  subject  of  a  Congenital  Paralysis    161 

219.  Diagram  of  the  Course    of  the  Principal  Conducting   Paths 

within  the  Spinal  Cord Erb.    213 

220.  Diagram  of  the  Cutaneous  Symptoms  in  Unilateral  Lesion  of 

the  Dorsal  portion  of  the  Spinal  Cord  on  the  left  side  ...  ,,        214 

221.  Section  of  the  Pons  on  a  level  with  the  origin  of  the  sixth  and 

seventh  Nerves ...     ...     ...     ,,        229 

222.  Attitude  of  the  Hand  in  Pachymeningitis  Cervicalis  Hyper- 

trophica      Charcot.    240 

223.  „  „  „  „  Leech.     241 

224.  Diagram  showing  the  Distribution  of  Anesthesia  in  Pachy- 

meningitis Cervicalis       244 

225.  Transverse  Section  of  the  middle  of  the  Cervical  Enlargement 

from  a  case  of  Hypertrophic  Cervical  Pachymeningitis Charcot.     245 

226.  Dura  mater  and  Cranial  Sinuses ...     ...Turner.    266 

227.  View  of  the   Brain  from  below— Distribution  of  Vessels. 

Ecker  and  Duret.  268 

228.  Inner  Surface  of  Right  Hemisphere — Distribution  of  Vessels      ,,  269 

229.  Outer  Surface  of  Left  Hemisphere — Distribution  of  Vessels      ,,  270 

230.  Diagram    showing    the  area    of    Distribution    of  the    Middle 

Cerebral  Artery        Charcot.     271 

231.  Diagram  of  the  Distribution  of  the  Vessels  at  the  Base  of  the 

Cerebrum    „  272 


Duret. 

273 

" 

274 

276 

Turner. 

279 

Henle. 

282 

Ecker. 

284 

)5 

285 

287 

Henle. 

288 

Ferrier. 

291 

Turner. 

293 

Pitres. 

295 

)? 

296 

296 

,, 

297 

)5 

297 

)5 

298 

Henle. 

302 

DESCRIPTION   OF  ILLUSTRATIONS.  XIX 

Fig.  Page. 

282.     Tertiary  Branches  of  one  of  the  main  Arteries  of  the  Cortex  of 
the  Brain     

233.  Medullary  Arteries ... 

234.  Transverse  Section  of  the  Cerebral   Hemisphere,  showing  the 

Distribution  of  the  Vessels    

235.  The  Occipital  Surface  of  the  Cerebellum 

236.  Base  of  the  Brain    

237.  Lateral  View  of  the  Human  Brain    

238.  View  of  the  Brain  from  below     ... 

239.  View  of  the  Median  Aspect  of  the  Eight  Hemisphere  of  the 

Brain    ,     

240.  Internal  View  of  the  Hemisphere  of  the  Cerebrum      

241.  Lateral  View  of  the  Human  Skull     

242.  Diagram  showing  the  Relations  of  the  Convolutions  to  the  Skull. 

243.  PrjE-frontal  Section  of  the  Cerebral  Hemisphere    ...     

244.  Pedunculo-frontal  Section 

245.  Frontal  Section        

246.  Parietal  Section       ...     ... 

247.  Pedunculo-parietal  Section 

248.  Occipital  Section     

249.  Basal  G-anglia  viewed  from  above 

250.  Longitudinal  and  Vertical  Section  of  the  Right  Hemisphere, 

showing  the  Cavity  of  the  Lateral  Ventricle  of  the  Caudate 

Nucleus      ...    ...-     ...  Dalton.    303 

251.  Vertical  Section  of  the  Brain  immediately  behind  the  Anterior 

Commissure  of  the  Third  Ventricle    Henle.  304 

252.  Section  of  a  Furrow  of  the  Third  Cerebral  Convolution  of  Man .  Meynert.  309 

253.  Pyramidal  Giant-Cell  from  the  Cortex  of  the  Brain     ...     ...     310 

254.  Vertical  Section  of  the  Brain  parallel  to  the  course  of  the 

Ascending  Fibres  of  the  Right  Cerebral  Peduncle Henle.    313 

255.  Horizontal  Section  of  the  Hemisphere  of  the  Brain,  close  to  its 

inferior  surface ,,        314 

256.  Transverse  Section  of  the  Hemisphere  of  the  Brain  at  a  little 

higher  elevation  than  i^ifi^.  255     :,  315 

257.  Horizontal  Section  of  the  Brain  of  a  child  nine  months  of  age.  Flechsig.  316 

258.  Transverse  and  Oblique  Section  of  the  Basal  Ganglia Henle.  318 

259.  Section  of  the  Anterior  Pyramid  of  the  Medulla  Oblongata. 

Debove  and  Gombault.     819 

260.  Transverse  Section  of  the  Crus  Cerebri    Krause.    321 

261.  Horizontal  Section  of  the  Basal  Ganglia  and  Internal  Capsule 

of  the  Brain  of  a  Nine-months  Embryo     323 

262.  Transverse  and  Vertical  Section  of  the  Basal  Ganglia ...    Henle.  324 

263.  Brain  of  Rabbit       ...     ...     Ferrier.  330 

264.  External  Surface  of  the  Foetal  Brain  at  six  months    ...Wagner.  330 

265.  Transverse  Section  of  the  Brain  of  the  Dog  on  a  level 

with  the  Corpora  Albicantia Carville  and  Duret  342 

266.  Ditto,  five  millimetres  in  front  of  the  Optic  Commissure    ,,  ,,  343 

267.  The  Left  Hemisphere  of  the  Monkey       Ferrier.  348 

268.  Upper  Surface  of  the  Hemisphere  of  the  Monkey „  349 

269.  Side  Views  of  the  Brain  of  Man „  350 

270.  Superior  Surface  of  the  Brain  of  Man      ,,  351 

271.  External  Convex  Surface   of  the  Brain   of  the  Adult 

Monkey      Broca  and  Gromier,     352 


XX  DESCRIPTION   OF  ILLUSTRATIONS. 

Pig.  Page. 

272.  External  Convex  Surface  of  the  Htiman  Brain     353 

273.  Upper  and  Lateral  Surfaces  of  the  Brain  of  the  Monkey  ...     ...  Munk.    356 

274.  Horizontal  Section  of  the  Eight  Hemisphere  parallel  with  the 

Fissure  of  Sylvius     Charcot.    365 

275.  Ditto  of  the  Crura  Cerebri  in  a  case  of  secondary  degeneration...       ,,  366 

276.  Transverse  Section  of  the  Cervical  Region  of  the  Spinal  Cord  — 

Lesion  of  the  Motor  Area  of  the  Cortex  of  the  Brain   ,,  366 

277.  Recent  Softening  of  the  Frontal  Lobe,  the  Island  of  Reil,  and 

Middle  Third  of  the  Lenticular  Nucleus Brissaud.    367 

278.  Transverse  Section  of  the  Crura  Cerebri  in  a  case  of  Secondary 

Degeneration     Young.  368 

279.  Ditto  of  the  Pons  in  ditto ...          „  368 

280.  Ditto  of  the  Medulla  Oblongata  in  ditto  ...     „  368 

281.  Ditto  of  the  Lower  End  of  the  Medulla  in  ditto „  369 

282.  Softening  of  the  Anterior  Segment  of  the  Internal  Capsule  and 

Secondary  Degeneration  in  the  Crus  Cerebri  ...     Brissaud.     370 

283.  Diagram  of  the  Optic  Thalamus,  Tegmentum,  and  Superior  Pe- 

duncles of  the  Cerebellum  in  a  case  of  Secondary  Degenera- 
tion     ...     ...     Mendel.    371 

284.  Portrait  of  the  Head  in  a  Case  of  Congenital  Deficiency  of  the 

Right  Parietal  Bone        ...     • 458 

285.  Portrait  of  a  Case  of  Double  Athetosis 461 

286.  ,,  „  Congenital  Spasmodic  Talipes 465 

287.  „  „  „  „  „        465 

288.  Vertical  Section  of  the  Brain  a  little  behind  the  knee  of  the 

Internal  Capsule      Charcot.    472 

289.  Horizontal  Section  of  the  Basal  Ganglia  and  Internal  Capsule 

in  a  Nine-months  Embryo     •••     474 

290.  Vertical  Section  of  the  Brain  on  a  level  with  the  posterior  part 

of  the  Internal  Capsule Charcot.    475 

291.  Diagram  of  the  Outer  Surface  of  the  Left  Hemisphere  of  the 

Brain  from  a  Case  of  Porencephalus Young.     488 

292.  Lateral  View  of  the  Cerebral  Hemisphere— the  Hemiplegia  of 

Infancy       Bourneville.    494 

293.  Lateral  View  of  the  Cerebral  Hemisphere —Brachial  Monospasm 

Dreschfeld.    496 

294.  Lateral  View  of  the  Cerebral  Hemisphere—  Convulsions  of  the 

Platysma     ...     ... Bramwell,     498 

295.  Portrait  of  a  Boy  the  subject  of  Conjugate  Deviation  of  the 

Eyes     ...     Thomson.     500 

296.  Lateral  View  of  the  Cerebral  Left  Hemisphere —Right  Hemiplegia. 

Lepine.    504 

297.  Lateral  View  of  the  Cerebral  Right  Hemisphere— Left  Hemiplegia. 

Charcot.    505 

298.  Vertical  Section  of  the  Cerebral  Left  Hemisphere— Right  Hemiplegia. 

Pitres,    506 

299.  Lateral  View  of  the  Left  Hemisphere— Right  Hemiplegia...     ...Atkins.     506 

300.  Superior  Surface  of  the  Brain,  Arrest  of  Development  of  the 

Right  Lower  Extremity    ...Oudin.     507 

301.  Superior  Surface  of  the  Cerebrum— Monoplegia  of  the  Left 

Lower  Extremity    Haddon.    508 

302.  Median  Aspect  of  the  Hemisphere,  same  case  is  in  i^iV- 301      ...        ,,         509 

303.  Lateral  View  of  the  Right  Cerebral  Hemisphere— Brachio- 

crural  Monoplegia Charcot  and  Pitres.    509 


DESCRIPTION   OF   ILLUSTRATIONS.  XXI 

Fig.  Page. 

304.  Vertical    Section    of    the    Cerebral    Hemisphere.       Focus    of 

Softening  in  Centrum  Ovale       ... Pitres.     510 

305.  Lateral  View  of  the  Right  Cerebral  Hemisphere  — Brachial 

Monoplegia •••  Pierret.     510 

306.  Lateral   View    of    the   Left    Cerebral    Hemisphere  —  Brachial 

Monoplegia Atkins.     511 

307.  Vertical  Section  of  the  Cerebral  Hemisphere.     Lesion  of  the 

Centrum  Ovale.     Paresis  of  Left  Arm      ...    Pitres,     512 

308.  Lateral    View    of    the    Right    Cerebral    Hemisphere  —  Facial 

Monoplegia ...     Charcot  and  Pitres,     513 

309.  Lateral    View    of    the    Right    Cerebral    Hemisphere — Facial 

Monoplegia  (left)      Hitzig.     513 

310.  Lateral    View    of    the    Right    Cerebral    Hemisphere — Facial 

Monoplegia  (left)     ...     ... Ballet.     514 

311.  Lateral  View  of   the  Left  Cerebral   Hemisphere — Unilateral 

Oculo-motor  Monoplegia       G-rasset.     521 

312.  Lateral  View  of  the  Left  Cerebral  Hemisphere — Word-blindness. 

Broadbent.    527 

313.  Vertical  Section  of  the  Cerebral  Hemisphex'e — Lesion  of  Cen- 

trum Ovale  of  Temporo-sphenoidal  Lobe Pitres.     532 

314.  Lateral  View  of  the  Left  Cerebral  Hemisphere— Word-deafness. 

Wernicke.     533 

315.  Vertical  Section  of  the  Cerebral  Hemisphere — Lesion  of  the 

Centrum  Ovale         Pitres.     537 

316.  Vertical  Section  of  the  Cerebral  Hemisphere — Lesion  of  the 

Centrum  Ovale — Aphasia      -     ,,        552 

317.  Diagram  of  the  Centres  engaged  in  Speech    Broadbent.     560 

318.  ,,  ,,  ,,  ,,  561 

319.  Horizontal  Section  of  the  Brain  of  a  Child  nine  months  of  age...Flechsig.    570 

320.  Schema  of  the  Semi-decussation  of  the  Fibres  of  the  Optic 

Commissure       Landois.  578 

321.  The  Base  of  the  Brain  and  adjoining  part  of  the  Spinal  Cord...    Henle.  580 

322.  Internal  View  of  the  Base  of  the  Skull    ... „  581 

323.  Diagram  illustrating  Alternate  Hemiplegia ...   Nothnagel.  586 

324.  Transverse  Section  of  the  Pons  on  a  level  with  the  Root  of  the 

Sixth  and  Seventh  Nerves     ...     ."     Erb.     590 

325.  Transverse  Section  of  the  Pons  on  a  level  with  the  Origin  of 

the  Trigeminus ...  ,,       592 

326.  Transverse  Section  of  the  Pons  on  a  level  with  the  Anterior  End 

of  the  Fourth  Ventricle „       593 

327.  Transverse  Section  of  the  Crus  Cerebri    ...     Krause.    595 

328.  Attitude  of  the  Hand  in  Paralysis  Agitans     ...Charcot.    746 

329.  „  „  „  „  ...     ...      „  747 

330.  Section  of  the  Cervical  Enlargement  of  the  Spinal  Cord  from  a 

case  of  Chorea Young,     779 

331.  Section  of  the  Cervical  Enlargement  of  the  Spinal  Cord  from 

a  case  of  Chorea       Bury    780 

332.  Tetanus— Opisthotonos ...     Sir  C,  Bell    799 


E  E  E  A  T  A. 


Volume  I. 

Page  144.  Line  11  from  top )  .     ,,  ,  ,,    ,         ,     •    „        i  .c     1,^1,  ,         1     •    , 

,,  ^.      ,,„         ,       rfor   'exophthalmoplegia     read     ophtnalmopleeria. 

„     145.  Line  15  from  top  ' 

,,    370.  Line  19  from  top,  for  "amaurosis"  read  "anosmia." 

„    632.  Line  6  from  top,  for  "right  arm"  read  "left  arm." 

,,     633.  Line  9  from  top,  for  "forearm"  read  "upper  arm." 

„     634.  Line  5  from  bottom,  for  "March,  1869,"  read  "  March  26th,  1864." 


BOOK    I. 


GENERAL  PATHOLOGY  OF  THE  NERVOUS  SYSTEM. 


GENERAL  PATHOLOGY  OF  THE  NERYOUS 

SYSTEM. 


CHAPTER  I. 

INTRODUCTION— THE  STRUCTURE  AND  FUNCTIONS 
OF  THE  NERVOUS  SYSTEM. 

Before  entering  upon  the  consideration  of  the  nervous  system, 
I  may  be  permitted  to  make  a  few  remarks,  by  way  of  in- 
troduction, on  the  fundamental  properties  of  living  matter. 
Every  kind  of  living  matter  is  found  to  be  a  complex  combi- 
nation of  carbon,  hydrogen,  oxygen,  and  nitrogen,  and  some 
secondary,  but  still  essential,  constituents.  The  peculiarities 
of  the  substance  of  living  bodies,  therefore,  do  not  depend  on 
the  existence  of  a  new  kind  of  matter,  but  on  new  combina- 
tions or  collocations  of  constituents  with  which  we  are  familiar 
in  their  separate  states,  and  in  their  simpler  combinations. 

But  a  great  many  persons  cannot  bring  themselves  to  believe 
that  the  forces  which  produce  the  forms  and  actions  of  living 
beings  are  the  same  as  those  which  are  operative  in  the  in- 
organic world.  Everyone  admits  that  certain  kinds  of  living 
action,  such  as  the  motions  of  the  limbs  by  muscular  contrac- 
tion, are  subject  to  mechanical  laws ;  but  some  think  that  the 
more  recondite  processes,  such  as  muscular  contraction  itself, 
are  under  the  control  of  a  higher  principle.  An  attempt  has 
been  made  in  all  ages  to  formulate  this  conception.  Aristotle 
assumed  the  existence  of  a  "  vegetative  soul "  to  account  for 
living  processes  and  actions.  Van  Helmont  called  the  principle 
of  life  "  Archseus,"  and  Stahl  called  it  "  Anima ;"  while  in 
modern  times  these  ideas  have  been  superseded  by  the  con- 
ception of  a  "  vital  force "  in  no  way  related  to  the  physical 
forces. 


4  STRUCTUKE  AND   FUNCTIOXS 

But  science,  especially  in  its  objective  aspect,  cannot  recog- 
nise the  dualism  which  would  ascribe  some  living  actions  to 
mechanical  forces,  and  reserve  others  for  the  supervision  of 
another  force  which  is  in  no  way  related  to  the  former.  No 
living  action  or  process  has  ever  been  rescued  from  the  un- 
known to  the  known  except  by  the  application  to  it  of  the 
laws  of  inorganic  nature.  Life  does  not  introduce  us  to  a 
new  order  of  force,  but  to  new  combinations  or  collocations  of 
the  forces  which  have  already  become  more,  or  less  familiar 
to  us  in  the  study  of  the  physical  and  chemical  sciences.  In 
one  word,  the  great  law  of  the  conservation  of  energy  is  as 
applicable  to  the  objective  study  of  living  beings  as  to  that  of 
any  part  of  the  universe  within  the  reach  of  our  observation. 

§  1.  Conservation  of  Energy. — The  principle  of  the  conser- 
vation of  energy  asserts  that  force  is  neither  created  nor  annihi- 
lated, and  that  its  quantity  in  the  universe  is  as  unalterable 
as  the  quantity  of  matter.  The  different  forms  of  force  may 
be  transmuted  into  one  another;  but  nothing  is  lost  in  the 
transfer.  Mechanical  force  may  pass  into  heat;  but  by  suit- 
able arrangements  the  heat  may  be  reconverted  into  nearly 
the  original  amount  of  mechanical  momentum. 

This  is  not  the  place  to  enter  on  an  exposition  of  the  doc- 
trine of  the  conservation  of  energy,  but  I  may  be  allowed  to 
remind  the  reader  that  the  various  forms  of  force  are  on 
ultimate  analysis  reducible  to  two  kinds — namely,  attraction 
and  repulsion.  When  two  bodies  which  attract  each  other  are 
separated  by  a  space,  the  system  possesses  energy,  or  a  power 
of  performing  work.  If  they  are  prevented  by  an  external 
force  from  obeying  their  attractions  by  moving  towards  one 
another,  the  energy  of  the  system  is  potential;  and  when  all 
hindrances  to  their  movement  towards  one  another  are  re- 
moved, the  energy  becomes  actual,  dynamic,  or  kinetic.  Sub- 
stances which,  instead  of  attracting,  repel  each  other,  must 
be  pressed  towards  one  another  by  some  external  force  before 
the  system  can  possess  energy;  so  long  as  this  external  force 
prevents  the  two  repelling  bodies  from  moving  away  from 
one  another,  the  energy  is  potential ;  and  when  all  hindrances 
to  the  free  action  of  their  mutual  repulsions  are  removed,  the 


OF   THE  NERVOUS  SYSTEM.  5 

energy  becomes  kinetic.  The  force  which  removes  all  the  ob- 
stacles to  the  motion  of  attracting  bodies  towards  each  other,  or 
of  repelling  bodies  away  from  one  another^  and  which  thus 
converts  the  potential  into  kinetic  energy,  is  called  the  libe- 
rating or  discharging  force.  Two  other  terms  are  employed  in 
describing  the  transformations  of  energy,  which  it  is  well  to 
remember.  When  two  bodies  are  so  related  that  a  small 
liberating  force  renders  kinetic  their  potential  energy,  then  the 
system  is  said  to  be  in  a  position  of  unstable  equilibriwm,  and 
when  the  system  either  possesses  no  potential  energy,  or  when 
a  relatively  large  liberating  force  must  be  applied  before  its 
potential  energy  can  be  rendered  kinetic,  it  is  said  to  be  in  a 
position  of  stable  equilibrium.  As  a  familiar  instance  of  un- 
stable equilibrium,  I  may  take  a  thin  book  from  my  table,  and 
place  it  on  end  on  the  floor.  A  slight  touch  at  the  free  end  of 
the  book  will  cause  its  centre  of  gravity  to  project  beyond  its 
base,  and  the  earth  and  the  book  will  then  rush  towards  one 
another — the  slight  touch  has  converted  the  potential  into  kinetic 
energy.  Now,  however,  when  the  book  rests  on  its  side,  a 
relatively  large  amount  of  external  force  must  be  applied  to  it 
before  it  can  give  out  any  actual  energy;  the  earth  and  the 
book  are  in  a  position  of  stable  equilibrium  in  relation  to  one 
another. 

§  2.  Fundamental  Properties  of  Living  Matter. — Let  us  now 
proceed  to  the  consideration  of  the  fundamental  properties  of 
living  matter.  The  most  casual  observation  must  convince 
anyone  that  organisms  are  not  an  aggregate  of  materials  heaped 
up  in  any  fashion;  but  that,  however  diverse  may  be  their 
forms,  they  are  constructed  in  an  orderly  manner.  Now,  sup- 
pose that  an  intelligent  inhabitant  of  Central  Africa,  on  visiting 
this  country,  had  been  struck  with  the  utility  of  brick  buildings, 
and  wished  to  acquire  a  knowledge  of  their  mode  of  construction, 
what  would  be  the  best  means  of  imparting  the  desired  informa- 
tion? We  should  show  him  that  the  house  is  mainly  composed 
of  walls ;  that  each  wall,  and  each  part  of  a  wall,  is  made  up  of 
bricks.  Having  shown  that  the  unit  of  composition,  or,  in  other 
words,  the  structural  unit  of  the  house,  is  a  single  brick,  we 
should  then  direct  him  to  make  a  special  study  of  the  mode  of 


6  STEUCTURE  AND   FUNCTIONS 

formation  and  properties  of  the  brick;  and  after  he  had  mastered 
the  details  of  brickmaking,  he  could  then  be  shown  how  brick  is 
united  to  brick  to  form  a  wall,  and  so  on,  until  he  was  taught 
how  a  house  is  built.  In  short,  in  order  usefully  to  study  such  a 
simple  construction  as  a  brick  house,  there  must  first  be  either  a 
real  or  an  ideal  breaking  down  of  the  building  into  its  con- 
stituents, and  then  either  a  real  or  an  ideal  putting  together  of 
the  constituents  to  form  the  building.  Analysis  and  synthesis 
are  both  necessary,  but  the  former  ought  to  precede  the  latter. 

If  we  subject  organisms,  in  the  first  place,  to  ideal  analysis,  we 
shall  find  that  each  is  composed  of  certain  mechanisms  or  organs; 
and  that  each  organ  is  composed  of  certain  definite  arrangements 
of  tissues;  and,  finally,  that  each  tissue  is  composed  of  structural 
units,  which,  for  the  sake  of  illustration,  we  may  call  "  organic 
bricks."  To  make  a  real  analysis  of  a  living  organism  is  a  much 
more  difficult  matter  than  to  make  a  similar  analysis  of  a  brick 
building,  since  the  living  properties  of  the  structural  unit  which 
we  wish  to  study  generally  escape  us  in  the  act  of  making  the 
analysis.  But,  fortunately,  even  in  the  higher  organisms  there 
are  some  units — such  as  the  white  blood-corpuscles — which  can 
be  kept  alive  for  some  time  after  detachment  from  the  parent 
organism,  and  in  which  the  fundamental  properties  of  the 
structural  unit  may  be  usefully  studied.  We  generally,  however, 
avail  ourselves  of  the  analysis  which  nature  has  made  ready  to 
our  hands.  It  is  not  possible  to  build  a  house  with  a  single  clay 
brick ;  but  it  is  possible  for  a  single  organic  brick  to  constitute  a 
complete  living  individual.  The  lowest  living  organisms — if, 
indeed,  they  are  entitled  to  be  called  organisms,  since  they  do 
not  possess  real  organisation — are  mere  specks  of  albuminoid 
matter,  the  protoplasm  of  biologists,  and  correspond  to  the 
structural  units  of  the  higher  organisms.  It  is  by  the  study  of 
these  lowly  organisms  that  we  must  expect  to  ascertain  the 
fundamental  properties  of  living  matter. 

Amongst  these  primordial  organisms,  probably  the  best 
adapted  for  the  study  of  the  fundamental  properties  of  life  are 
the  amoebae,  both  on  account  of  their  simplicity  and  of  their 
similarity  to  the  white  corpuscles  of  vertebrate  blood.  There 
are  several  kinds  of  these,  but  all  of  them  may  be  arranged 
under  three  leading  orders  : — 


OF  THE   NERVOUS   SYSTEM.  7 

(1)  Organisms  consisting  of  a  simple  speck  of  protoplasm, 

such  as  the  Protamceha  primitiva  found  by  HseckeP 
in  fresh  water. 

(2)  Organisms  more  or  less  similar  to  the  above,  but  possessing 

a  distinct  nucleus. 

(3)  Similar  organisms,  exhibiting,  along  with   the  gra'nular 

protoplasmic  interior  or  endosarc,  a  more  solid  external 
layer  or  ectosarc.  The  external  layer,  instead  of  being 
a  membrane,  is  sometimes  represented  by  a  shell ;  but 
the  former,  owing  to  its  similarity  to  the  membrane 
surrounding  the  cells  which  form  the  tissues  of  the 
higher  organisms,  is  of  more  importance  to  us. 

This  classification  shows  that  the  protoplasm  is  the  funda- 
mental substance,  without  which  no  organism  can  exist,  and 
that  the  other  constituents  found  in  the  unit  are  mere  speciali- 
sations of  this  fundamental  substance.  A  knowledge  of  the 
primary  properties  of  life  will,  therefore,  be  best  gained  by  the 
study  of  the  first  order  of  unit. 

§  3.  Protoplasm. — If  one  of  these  lowly  organisms  be  watched, 
it  is  seen  to  throw  out  processes  of  its  substance,  and  then  to 
retract  them — changes  which  are  accompanied  by  a  flux  and 
reflux  of  its  granular  substance, — and  it  is  able  by  this  means 
to  perform  a  certain  amount  of  locomotion.  The  amoeba  is 
contractile. 

Amoeboid  movements  occur  under  two  conditions.  In  the 
first  place,  contact  with  foreign  bodies,  and  chemical  and  elec- 
trical agents,  call  forth  these  movements.  These  disturbing 
causes  act  as  liberating  forces  in  rendering  kinetic  the  energy 
potential  in  the  protoplasm  ;  and,  as  is  usual  in  such  cases,  the 
energy  set  free  is  out  of  all  proportion  to  the  cause  which  deter- 
mines the  transformation.  A  disturbing  force  which  determines 
a  discharge  of  energy  in  living  matter  is  called  a  stimulus. 
In  the  amoeba,  the  application  of  a  stimulus  leads  to  movement, 
but  in  some  cases  the  energy  set  free  by  the  discharge  assumes 
the  form,  not  of  contraction,  but  of  heat.     We  want,  therefore, 

'  Haeckel  (Ernst).  Entwickelungegeschichte  der  Organismen.  Erster  Band. 
Berlin,  1866.    s.  275. 


8  STEUCTURE  AND  FUNCTIONS 

a  generic  term  to  express  the  fact  that  when  living  matter  is 
acted  on  by  a  stimulus  there  is  an  active  development  of  energy, 
whatever  the  form  the  energy  assumes.  The  term  employed  for 
this  purpose  is  irritability,  and  a  tissue  which  responds  to  a 
stimulus  by  an  expenditure  of  energy  is  said  to  be  irritable. 
Irritability,  therefore,  is  the  genus,  of  which  contractility  is  the 
most  important  species;  the  former  is,  but  the  latter  is  not, 
co-extensive  with  life. 

But  in  the  second  place,  the  movements  of  the  amoeba  cannot 
always  be  referred  to  the  action  of  external  stimuli ;  the  energy 
is  frequently  set  free  in  consequence  of  internal  changes,  and 
the  movements  are  then  called  spontaneous  or  automatic. 
It  may  therefore  be  said  that  protoplasm  is  irritable  and 
automatic. 

We  have  already  seen  that  when  there  is  an  expenditure  of 
energy,  matter  has  fallen  from  a  relatively  unstable  to  a  rela- 
tively stable  position,  in  which  it  possesses  a  comparatively 
small  amount  of  energy  or  none.  And  if  no  counterbalancing 
actions  were  proceeding,  the  store  of  energy  in  the  substance  of 
the  amcBba  would  soon  be  exhausted ;  and,  indeed,  this  store 
may  be  exhausted  at  one  stroke  by  the  application  of  a  powerful 
stimulus.  This  action  may  be  very  readily  watched  with  an 
organism  closely  allied  to  the  amceba — the  Protococcus  pluvialis. 
If,  while  watching  its  movements  under  the  microscope,  a  drop 
of  dilute  alcohol,  or  a  weak  solution  of  quinine  or  strychnine,  be 
placed  at  the  edge  of  the  cover-glass,  when  the  chemical  agent 
makes  its  way  to  the  organism  its  ordinary  movements  give 
place  to  one  or  two  violent  contractions,  which  are  followed  by 
quiescence.  In  this  condition  no  further  stimulation  will  evoke 
movements;  the  protoplasm  has  lost  its  irritability.  There 
is  one  violent  explosion  of  energy,  ending  in  complete 
expenditure  of  the  stock.  In  this  case  the  expenditure  is 
followed  by  permanent  loss  of  irritability,  or  death,  probably 
because  the  chemical  stimulus  continues  to  act  upon  it ;  but 
when  the  action  of  the  stimulus  is  temporary,  as  with  an  elec- 
tric stimulus,  the  loss  of  irritability  induced  may  be  followed 
by  gradual  restoration.  But,  whether  the  loss  of  irritability  be 
temporary  or  permanent,  when  it  is  caused  by  the  sudden 
application  of  a  violent   stimulus  the   effect  is   called  shock 


^ 


OF  THE  NERVOUS  SYSTEM.  9 

The  loss  of  irritability  may  also  be  caused  by  the  prolonged 
application  of  a  moderate  stimulus,  if  the  conditions  necessary 
to  the  acquirement  of  a  new  stock  of  irritable  matter  are 
prevented.  Under  these  circumstances  the  state  is  called 
exhaustion. 

The  allusion  just  made  to  the  absorption  by  the  protoplasm  of 
the  amoeba  of  a  new  stock  of  energy  leads  us  to  the  consideration 
of  a  second  group  of  fundamental  properties  of  living  matter. 
Certain  substances  serving  as  food,  when  received  into  its  body, 
are  manufactured  into  new  protoplasm.  This  process  is  called 
assimilation.  The  protoplasm,  however,  is  continually  under- 
going chemical  change  (metabolism) ;  the  old  protoplasm  is 
broken  up,  and  the  products  of  disintegration  are  cast  out  of  the 
body  as  excretions.  This  process  is  termed  disassimilation. 
Some  of  the  products,  however,  are  probably  retained  within 
the  body  for  a  time,  and  used  in  the  solution  and  preliminary 
changes  of  the  raw  food,  and  these  are  termed  secretions. 

But  all  the  protoplasm  formed  by  an  amoeba  is  not  imme- 
diately disintegrated;  some  of  it  is  added  to  its  substance,  con- 
stituting growth. 

§  4.  Nucleus. — When  the  amoeba  attains  a  certain  size,  it 
generally  resolves  itself  by  fission,  or  by  other  means,  into  two 
or  more  parts,  each  of  which  is  capable  of  living  as  a  new  indi- 
vidual, which  passes  through  phases  of  life  similar  to  those  of  the 
parent  from  which  it  is  derived.  This  process,  then,  represents 
the  first  beginnings  of  two  great  living  functions — reproduction 
and  inheritance.  So  far  we  have  spoken  of  the  protoplasm  as 
being  the  fundamental  agent  which  exhibits  all  the  properties  of 
life,  and  there  can  be  little  doubt  that  it  exhibits  the  great 
functions  at  present  under  consideration.  When,  however,  the 
protoplasm  becomes  so  far  differentiated  as  to  possess  a  nucleus, 
the  latter  constituent  appears  to  preside  in  a  peculiar  manner 
over  the  functions  of  reproduction  and  inheritance.  In  the 
second  order  of  amcebse  the  nucleus  is  seen  to  divide  into  two  or 
more  parts  prior  to  the  fission  of  the  protoplasm.  When  these 
units,  instead  of  parting  company  and  each  leading  a  separate 
life  of  its  own,  aggregate  so  as  to  form  a  compound  organism  or 
a  compound  tissue,  this  process  of  fission  subserves  the  great 


10  STRUCTUEE  AND   FUNCTIONS 

function  of  growth,  since  the  organism  or  tissue  grows  not  so 
much  by  increase  in  the  size,  as  by  multiplication  in  the  number 
of  units. 

§  5.  Cell-Memhrane. — Two  of  the  constituents  of  the  unit 
have  been  passed  in  review.  The  nucleus,  being  of  denser 
consistence  than  the  protoplasm,  and  presiding,  as  we  have 
supposed  it  to  do,  over  the  great  functions  of  reproduction  and 
inheritance,  tends  to  make  the  offspring  like  the  parents.  The 
protoplasm,  on  the  other  hand,  being  of  a  semi-fluid  consistence, 
and  adapting  itself,  as  it  does,  to  different  circumstances  by 
changes  of  form,  tends  to  introduce  variety,  and  to  make  the 
progeny  unlike  the  parents.  But  this  power  of  adaptation, 
although  very  varied  in  degree,  is  only  of  one  kind — namely, 
contraction  of  the  protoplasm ;  and  the  fact  that  a  stimulus 
produces  a  contraction  at  one  time  does  not  enable  the  proto- 
plasm to  respond  better  to  a  similar  stimulus  a  second  time. 
So  far  there  is  no  principle  of  improvement  or  progress.  Under 
these  circumstances  we  turn  to  the  third  constituent  of  the  unit, 
namely  the  cell-membrane.  The  membrane  in  the  first  instance 
limits  to  a  large  extent  the  degrees  of  adaptation  of  the  proto- 
plasm. Being  of  denser  consistence,  it  offers  greater  passive 
resistance  to  external  forces,  and  the  flow  of  nourishment  towards 
the  interior  is  retarded,  so  that  the  amount  of  irritable  matter 
at  the  disposal  of  the  organism  is  diminished.  The  powers  of  the 
organism  are  thus  greatly  limited  by  the  membrane.  But  if 
the  membrane  diminishes  the  degrees,  it  increases  the  kinds  of 
adaptation.  The  increased  density  of  the  ectosarc  enables  it  to 
offer  a  certain  amount  of  passive  resistance  to  external  forces, 
and  the  endosarc  is  therefore  more  free  to  expend  its  energies  in 
internal  action.  And  although  the  membrane  is  not  an  active 
agent  in  producing  adaptations,  it  tends  to  fix  and  perpetuate 
those  adaptations  which  are  frequently  repeated,  and  in  the 
compound  organisms  thus  makes  possible  progressive  improve- 
ment through  successive  modifications. 

§  6.  Cell-Contents. — Besides  the  protoplasm  and  nucleus, 
other  substances  are  found  enclosed  in  the  cell-membrane,  tech- 
nically called  cell-contents.     Sometimes  the   cell-contents  are 


OF  THE  NERVOUS  SYSTEM.  11 

fluid,  and  then  generally  belong  to  the  secretions  or  excretions 
already  mentioned.  Generally,  however,  they  are  solid,  such  as 
inorganic  crystals,  organic  concretions  like  starch  corpuscles,  fat 
granules,  chlorophyl,  hgemoglobin,  and  various  pigmentary 
granules.  Some  of  these,  as  starch  .and  fat,  are  stores  of  poten- 
tial energy;  chlorophyl  and  hsemoglobin  appear  to  be  subservient 
to  the  respiratory  function,  while  the  accumulation  of  pigment 
has  obscure  relations  to  other  special  functions. 

§  7.  Assimilation  and  Disassimilation. — The  two  ^most 
fundamental  processes  of  life,  then,  are  assimilation,  or  the 
process  by  which  irritable  matter  is  formed  and  energy  rendered 
potential;  and  disassimilation,  or  that  by  which  the  irritable 
matter  is  broken  up  and  energy  rendered  kinetic.  These  pro- 
cesses underlie  and  render  possible  the  other  processes  of  life. 
When  assimilation  is  in  excess  of  disassimilation — or,  in  more 
general  terms,  when  integration  is  in  excess  of  disintegration — 
growth  takes  place  ;  and  when  growth  proceeds  to  a  certain 
extent,  a  portion  of  the  material  is  given  away  for  the  produc- 
tion of  a  new  individual.  On  the  other  hand,  the  energy 
rendered  active  during  the  disintegration  of  the  irritable  matter 
is  chiefly  applied  in  those  lower  organisms  to  the  execution  of 
movements,  and,  to  some  small  extent,  to  the  production  of  heat. 
All  these  functions,  then,  aid  each  other  in  the  preservation  of 
the  individual  and  of  the  race.  Were  that  addition  to  the  bulk 
of  the  organism  which  constitutes  growth  to  cease,  reproduction 
would  soon  become  impossible,  since,  in  the  absence  of  the 
former,  the  process  of  fission,  which  is  the  essential  factor  of  the 
latter,  would  soon  diminish  the  size  of  the  organism  to  a  point 
incompatible  with  life ;  and  that  growth  could  not  proceed  far 
without  reproduction  is  too  manifest  to  require  pointing  out. 
These  functions  are  in  their  turn  dependent  on  the  contractile 
power  of  the  protoplasm,  since  without  the  latter  property  the 
circulation  of  materials  which  is  necessary  to  life  would  cease. 

§  8.  Antagonism  between  Growth,  Reproduction,  and  Action. 
But  although  the  growth,  reproduction,  and  motor  functions  of 
these  simple  organisms  aid  each  other  in  the  maintenance  of  the 
organism,   there   are   also    fundamental    antagonisms    between 


12  STRUCTURE  AND   FUNCTIONS 

them.  Whenever  multiplication  occurs,  it  is  clear  that  the 
parent  individual  must  part  with  a  certain  amount  of  material, 
and  that  its  bulk  must  be  diminished  by  the  bulk  of  the  matter 
given  away  (Spencer^).  Nutriment  may  be  applied  either  to 
the  growth  of  the  parent  or  to  the  production  of  one  or  more 
new  individuals ;  but  it  cannot  at  one  and  the  same  time  be 
applied  to  both  purposes.  Every  bit  of  material  given  away  to 
form  a  new  unit  is  a  deduction  from  the  size  of  the  parent ;  and 
when  the  latter  frequently  parts  with  material  for  the  production 
of  progeny,  its  size  is  diminished  in  a  corresponding  degree ;  in 
other  words,  rapid  reproduction  is  accompanied  by  units  of  small 
size.  Again,  an  organism  may  use  its  nutriment  in  executing 
movements ;  and  when  movements  are  executed,  the  nutriment 
must  be  transformed,  just  as  coal  must  be  transformed  in  order 
to  put  our  locomotives  in  motion ;  and  when  it  is  transformed, 
it  can  neither  be  added  to  the  size  of  the  parent  nor  devoted  to 
the  production  of  a  new  individual.  A  fresh  supply  of  coal 
may  be  disposed  of  in  several  ways  :  it  may  be  added  to  the  pre- 
vious stock,  given  away,  or  burnt  ;  but  it  cannot  at  one  and  the 
same  time  be  stocked,  given  away,  and  burnt.  And  so  it  is  with 
respect  to  the  disposal  of  nourishment  by  protoplasm  :  it  can  be 
applied  to  increase  the  size  of  the  organism,  to  its  multiplication, 
or  to  the  execution  of  movements ;  but  so  much  of  it  as  is 
applied  in  one  direction  cannot  be  applied  in  either  of  the  other 
directions. 

Once  more :  when  the  protoplasm  is  surrounded  by  a  dense 
membrane,  the  flow  of  nourishment  into  it  is  much  retarded ; 
and  as  an  organism  can  neither  expend,  nor  add  to  its  bulk,  nor 
give  away  what  it  does  not  receive,  one  surrounded  by  a  dense 
membrane  (or  shell)  can  neither  move  actively,  nor  increase 
rapidly  in  size,  nor  multiply  quickly.  The  membrane  gives 
form,  and  fixity,  and  permanence,  and  resisting  power  to  the 
protoplasm ;  but  these  properties  are  gained  at  the  expense  of 
the  motor  functions,  growth,  and  reproduction.  There  is,  in  short, 
a  mutual  antagonism  between  each  and  all  of  these  functions,  so 
that  increase  of  activity  in  one  direction  involves  decrease  of 
activity  in  the  other  directions. 

»  Spencer  (Mr.  Herbert).  The  Principles  of  Psychology.  Vol.  II.,  1870,  p.  391 
et  seq. 


OF  THE  NERVOUS   SYSTEM.  13 

In  the  construction  of  the  higher  animals,  the  units,  instead 
of  parting  company,  and  each  living  an  independent  existence, 
aggregate,  and  every  new  unit  formed  becomes  incorporated 
with  the  general  mass.  But  a  simple  aggregation  of  living 
units  having  similar  properties  would  not  confer  any  advan- 
tages on  the  organism ;  while  the  units  themselves  would 
greatly  lose  by  the  fact  of  their  contact.  One  effect  of  the 
contact  is  that  the  surfaces  exposed  to  the  environment,  and 
through  which  food  can  be  absorbed,  are  greatly  diminished, 
and  their  opportunities  of  obtaining  food  when  associated  are 
less  than  when  each  unit  is  free.  When,  therefore,  we  see  an 
organism  of  considerable  dimensions,  we  may  be  quite  sure  that 
the  units  have,  by  the  very  fact  of  their  association,  gained 
advantages  in  certain  directions,  even  if  these  are  counter- 
balanced by  losses  in  other  directions. 

§  9.  Antagonism  between  the  Size  of  Units  and  Absorption 
of  Nourishment. — It  has  just  been  stated  that  both  the  pre- 
sence of  a  dense  cell-membrane,  and  the  association  of  units  to 
form  an  aggregate,  must  retard  the  exchanges  of  material  that 
are  constantly  taking  place  between  the  substance  of  living  cells 
and  the  surrounding  substances  which  are  utilised  by  them  as 
food ;  and  it  may  now  be  remarked  that  simple  increase  in  the 
size  of  the  units  must  necessarily  have  a  similar  effect.  That  an 
increase  in  the  size  of  a  cell  is  followed  by  a  relative  diminution 
of  material  exchanges  is  readily  proved  by  the  fact  that  the 
surface  which  a  large  cell  presents  for  the  absorption  of  nourish- 
ment does  not  increase  in  a  degree  proportionate  with  its  bulk. 
The  mass  of  a  body  increases  as  the  cube,  while  the  surface  only 
increases  as  the  square,  of  the  dimensions  (Spencer^).  When, 
for  instance,  a  cell  has  doubled  its  dimensions  its  mass  is  eight 
times,  while  its  surface  is  only  four  times,  the  original  size.  It 
is  evident,  therefore,  that  a  small  cell  presents,  in  proportion  to 
its  bulk,  a  larger  surface  to  its  environment  for  the  absorption  of 
nourishment  than  a  large  cell,  and  consequently  material  ex- 
changes take  place  more  readily  in  the  former  than  in  the  latter. 
It  is  not  very  easy  to  find  inductive  evidence  illustrative  of  this 
law,  inasmuch  as  increase  in  the  size  of  the  cell  is  usually  asso- 

1  Spencer.     Op.  Cit.    Vol.  I.,  p.  123. 


14  STRUCTURE  AND   FUNCTIONS 

ciated  with  increase  in  the  density  of  its  cell  wall ;  so  that  it  is 
not  possible  to  determine  how  much  of  the  diminution  of  the 
material  exchanges  is  to  be  attributed  to  each  factor.  The  white 
blood-corpuscles  are  of  small  size,  and  they  are  placed  in  the 
most  favourable  circumstances  for  obtaining  food,  inasmuch  as 
their  surfaces  are  bathed  in  a  highly  nutrient  fluid ;  while  large 
cartilage  cells  are,  on  the  other  hand,  always  placed  in  the  most 
unfavourable  circumstances  for  obtaining  nourishment,  inasmuch 
as  they  are  removed  to  a  considerable  distance  from  the  vessels 
by  which  they  are  supplied  with  nutrient  fluid.  But  during 
health  the  supply  of  nourishment  to  the  tissues  must  be  propor- 
tionate to  the  demand ;  hence  it  may  be  inferred  that  rapid 
material  exchanges  take  place  in  the  former,  and  that  the 
exchanges  in  the  latter  are  very  slow.  It  is  impossible,  however, 
to  determine  how  much  of  the  difference  in  the  nutritive  activi- 
ties of  the  two  units  is  to  be  attributed  to  the  difference  in  their 
sizes,  and  how  much  to  the  absence  of  a  cell  wall  in  the  case  of 
the  white  corpuscles  and  the  presence  of  a  dense  intercellular 
substance  in  the  case  of  cartilage  cells.  It  is  worthy  of  remark, 
however,  that  in  articular  cartilage,  the  smaller  and  embryonic 
cells  are  found  nearer  the  blood-vessels  than  the  larger  and  older 
cells;  and  there  can  be  little  doubt  that  a  similar  relationship  exists 
between  the  blood-vessels  and  embryonic  cells  in  other  tissues. 

§  10.  Differentiation  of  Structure  and  Specialisation  of 
Function. — In  social  organisms  growth  is  rendered  possible  by 
the  specialisation  of  function  which  is  denominated  "  division  of 
labour ;"  and  the  formation  of  a  society  of  living  units  renders 
possible  a  similar  specialisation  of  function  which  has  been 
aptly  named  "  a  physiological  division  of  labour."  This  "  divi- 
sion of  labour"  does  not  introduce  us  to  a  new  property  of 
protoplasm,  but  merely  to  a  new  principle,  whereby  the  pro- 
perties with  which  we  are  already  familiar  may  be  combined  in 
various  ways.  Certain  groups  of  the  constituent  units  become 
adapted  for  the  manifestation  of  one  or  a  few  only  of  the 
fundamental  properties  of  protoplasm,  to  the  complete  sub- 
ordination of  the  other  properties.  This  can  be  done  with 
advantage  to  the  organism  only  on  condition  that  other  groups 
of  units  become  adapted  for  the  manifestation  of  the  properties 


^ 


or  THE  NERVOUS   SYSTEM.  15 

which  have  become  subordinate  in  the  first  group.  In  the 
higher  organisms  one  group  of  units  becomes  pre-eminently 
contractile ;  a  second  pre-eminently  irritable  and  automatic ; 
other  groups  become  respectively  secretory,  excretory,  respira- 
tory, and  metabolic ;  while  another  group  becomes  specially 
adapted  for  reproduction ;  and  a  final  group  possesses  only  a 
passive  or  mechanical  function. 

"  The  physiological  division  of  labour "  has  for  its  mor- 
phological correlative  "differentiation  of  structure;"  and  the 
groups  of  units  which  assume  special  functions,  correspond  to 
the  various  tissues.  In  the  formation  of  the  tissues  the  cell- 
membrane  assumes  great  importance.  It  is  evident  that  if 
the  units  of  the  tissues  of  a  compound  organism  were  entirely 
composed  of  the  semi-fluid  substance  termed  protoplasm,  they 
would  not  have  sufficient  tenacity  to  stick  together.  In  the 
formation  of  structure,  therefore,  the  units  must  be  surrounded 
by  a  membrane ;  and  when  the  membranes  of  adjoining  units 
become  amalgamated,  they  are  called  intercellular  substance. 
The  disposition  of  the  membrane  or  of  the  intercellular  sub- 
stance, and  the  relative  amounts  of  the  different  constituents 
of  the  unit,  must  vary  according  to  the  function  of  the  tissue. 
When  the  function  of  a  tissue  is  of  a  passive  nature — such  as 
that  of  cartilage — a  relatively  large  amount  of  intercellular 
substance  is  present ;  and  if,  in  addition,  the  tissue  requires 
rigidity,  the  intercellular  substance  is  strengthened  by  the  de- 
position of  other  materials,  such  as  carbonate  and  phosphate  of 
lime  in  bone.  When,  on  the  other  hand,  the  tissue  is  actively 
growing,  the  proportion  of  intercellular  substance  to  protoplasm 
is  small,  as  in  granulation  tissue ;  and  when  the  units  multiply 
rapidly,  the  intercellular  substance  disappears,  the  nucleus  be- 
comes conspicuous,  and  the  tissue  breaks  up  into  separate 
units,  as  in  pus.  We  also  meet  with  independent  units,  without 
membrane,  in  the  white  corpuscles  of  the  blood,  whose  functions 
appear  to  be  of  a  metabolic,  and  therefore  of  an  elementary, 
character.  When  material  is  stored  up  in  the  tissue  for  future 
use,  then  the  cell-contents  come  into  prominence.  The  tissues 
which  perform  active  functions,  as  muscle  and  nerve,  must  be 
composed  of  a  due  admixture  of  membrane  and  protoplasm. 
The  transformation  of  the  protoplasm  supplies  the  motor  force ; 


16  STRUCTURE  AND   FUNCTIONS 

and  the  disposition  of  the  membrane  gives  fixity  to  the  arrange- 
ments, and  determines  the  direction  in  which  the  energy  is 
expended.  The  burning  of  coal  in  our  furnaces  supplies  the 
power  which  moves  our  factories ;  but  the  structural  arrange- 
ments of  the  machinery  determine  whether  the  factory  shall 
be  adapted  for  weaving  or  spinning,  or  for  the  manufacture  of 
wool,  cotton,  or  silk.  And  as  the  structural  arrangements 
determine  the  functions  of  the  factory,  so  it  is  with  living 
tissues.  The  active  tissues  must  therefore  have  a  much  more 
elaborate  arrangement  of  the  intercellular  substance  than  the 
passive  tissues,  so  that  the  energy  given  out  by  the  transfor- 
mation of  their  protoplasm  may  be  directed  to  definite  ends; 
and  while  the  intercellular  substance  must  be  sufficiently  dense 
to  give  fixity  to  the  arrangements,  it  must  not  be  so  dense  as 
greatly  to  retard  the  flow  of  nourishment  from  the  blood  to 
the  protoplasm:  otherwise  the  function  of  the  tissue  would  be 
diminished  as  surely  as  a  scanty  supply  of  coal  would  diminish 
the  work  of  the  factory.  It  will  be  readily  understood,  from 
the  antagonism  between  reproduction  and  active  expenditure 
of  energy,  that  a  tissue  which  is  performing  an  active  function 
cannot  have  its  units  multiplying  rapidly;  and  if  from  any 
cause  these  units  begin  to  multiply,  the  capacity  of  the  tissue 
for  the  display  of  function  will  become  impaired. 

§  11.  Integration  of  Structure. — In  the  formation  of  the 
higher  organisms,  the  process  of  differentiation  which  ends  in  the 
formation  of  the  tissues  must  be  accompanied  at  every  step  by 
corresponding  integration,  whereby  the  tissues  become  united  to 
form  mechanisms  or  organs.  Each  organ  is  built  up  of  a  com- 
bination of  tissues,  and  this  is  especially  true  of  those  organs 
which  perform  active  functions.  The  fundamental  tissue  of 
each  organ  corresponds  to  its  main  function;  but  it  is  packed 
together  to  form  an  organ  by  means  of  a  passive  tissue. 

Simultaneously  with  the  integration  of  the  tissues  to  form 
organs,  there  goes  on  a  corresponding  integration  of  organs  to 
form  the  individual.  Some  of  these  organs  are  devoted  to  the 
accumulation  and  elaboration  of  nutriment ;  others  to  its 
absorption  and  distribution ;  and  others  to  the  active  expendi- 
ture of  the  nourishment,  as  in  animal  locomotion, — and  this 


OP  THE  NERVOUS   SYSTEM.  17 

necessitates  the  formation  of  other  arrangements  for  the  removal 
of  waste  materials ;  and  lastly,  the  integration  is  completed  by 
the  various  tissues  and  organs  being  brought  into  close  connection 
under  a  central  regulative  organ,  by  means  of  which  the  various 
actions  of  the  individual  are  duly  co-ordinated. 

§  12.  Passage  from  the  General  to  the  Special  in  both  Struc- 
ture and  Function. — We  have  seen  that,  when  an  organism 
consists  of  an  aggregation  of  units  without  any  definite  arrange- 
ments, each  part  is  able  to  perform  all  the  vital  functions.  Each 
part  is  irritable,  automatic,  contractile,  metabolic,  excretory  and 
reproductive ;  and  it  is  only  as  fast  as  this  originally  uniform 
tissue  becomes  differentiated  that  each  part  acquires  the  power 
of  performing  more  perfectly  a  few  functions,  and  ultimately  one 
special  function,  while  losing  to  a  greater  or  less  extent  the 
power  of  performing  the  general  functions.  The  expanded 
tentacle  of  a  zoophyte,  on  being  touched,  immediately  contracts, 
and  after  a  time  it  expands,  apparently  from  its  own  inherent 
activity.  The  same  tissue  is  sensitive  to  external  impressions  or 
irritable,  as  well  as  automatic  and  contractile.  Of  essentially  the 
same  nature  appears  to  be  the  mechanism  concerned  in  the 
movements  of  the  leaves  of  carnivorous  plants  :  the  tissue  which 
receives  the  impression  also  closes  the  leaves  by  its  contraction, 
and  after  a  time  expands  them  by  its  own  inherent  activity. 
Such  actions  foreshadow  the  functions  of  nervous  tissues,  but 
they  fall  short  of  true  nervous  action.  In  Hydra  the  internal 
end  of  an  ectodermic  cell  is  prolonged  into  a  process,  which 
assumes  the  contractile  function  ;  while  the  external  end  of  the 
cell  becomes  specially  sensitive  to  external  impressions.  The 
internal  end  being  shielded  from  external  influences,  tends  to 
contract  only  when  it  receives  a  stimulus  through  the  external 
end ;  and  the  latter  always  tends  to  lose  its  contractile  property, 
the  more  its  exposed  position  requires  it  to  determine  when 
the  former  shall  be  made  to  contract.  In  other  words,  the 
internal  end  performs  the  work,  while  the  external  determines 
when  the  work  shall  be  done  :  the  one  is  operative,  the  other 
regulative. 

This  differentiation  of  structure  is  carried  still  further  in 
Beroe,  where  the  internal  and  external  ends  of  the  ectodermic 
VOL.  I.  C 


18  STRUCTURE  AND  FUNCTIONS 

cell  are  represented  by  two  different  cells  connected  by  a  tliin 
fibre.  The  changes  set  up  in  the  external  or  sensitive  cell  are 
conducted  through  the  fibre  to  the  internal  cell,  which  it  excites 
to  contract.  This  new  arrangement  of  fibre  introduces  us  to 
a  new  special  function.  A  part  of  the  tissue  is  set  apart  for 
conveying  waves  of  disturbance  from  the  sensitive  cell  to  the 
work  cell.  By  this  means  a  molecular  motion  on  the  surface  is 
followed  by  a  molar  motion  in  the  interior,  the  two  being  at  some 
distance  from  each  other,  and  co-ordinated  by  the  internuncial 
function  of  the  fibre.  The  next  step  of  development  consists  in 
the  differentiation  of  the  external  or  sensitive  cell  into  two  cells ; 
the  one  of  which  becomes  specialised  for  responding  to  external 
stimulation  alone,  and  the  other  for  automatic  action.  The 
latter  will  perform  its  functions  best  by  being  shielded  from 
external  influences,  and  it  will  therefore  be  withdrawn  from  the 
surface  of  the  body  ;  while  the  former  will  retain  its  superficial 
position  in  order  that  it  may  respond  the  better  to  external 
changes ;  and  each  of  these,  by  being  relieved  of  one  kind  of 
action,  will  perform  more  efiiciently  the  action  or  actions  it 
retains.  The  fibre  which  originally  connected  the  ectodermic 
cell  and  the  contractile  process  now  connects  the  latter  with  the 
automatic  cell ;  and  a  new  fibre  is  required  to  connect  the 
automatic  with  the  sensitive  cell.  The  automatic  cell  is  a  centre 
to  which  disturbances  originating  in  the  sensory  cell  are  conveyed, 
and  from  which  issue  impulses  to  the  work-organs ;  hence  the 
fibre  which  connects  it  with  the  sensory  cell  is  rightly  called  the 
afferent,  and  that  uniting  it  with  the  work-organs  the  efferent 
fibre.  The  automatic  cell  is  at  present  represented  as  being 
engaged,  both  in  spontaneous  action  and  in  modifying  afferent 
impulses  previous  to  their  being  passed  on  to  the  efferent  fibres. 
But  the  central  cell  becomes  by-and-by  differentiated  into  two 
cells,  the  one  of  which  is  restricted  mainly  to  automatic  action, 
and  the  other  to  the  co-ordination  of  afferent  impulses  previous 
to  their  conversion  into  the  outgoing  discharge.  The  latter  con- 
stitutes what  is  called  reflex  action. 

The  fundamental  fact,  however,  which  concerns  us  at  present, 
is  that  the  active  elements  of  which  the  nervous  tissues  are  com- 
posed consist  of  cells  and  ffhres.  We  must  now  glance  rapidly 
at  the  more  important  properties  of  these  cells  and  fibres. 


OF   THE  NEEVOUS   SYSTEM.  19 

§  13.  Oanglion  Cells. — The  ganglion  cells  possess  granular 
contents,  and  a  vesicular  nucleus  with  a  nucleolus.  They  vary 
much  in  size  and  form. 

(1)  Apolar  Ganglion  Cells. — Some  of  the  cells  are  small, 
generally  spherical  or  ovoid,  and  have  a  regular  uninterrupted 
outline.  These  cells  are  also  called  apolar,  from  the  fact  that 
they  do  not  possess  any  processes.  It  is  probable  that  the 
majority  of  such  cells  are  embryonic  forms. 

(2)  Caudate  Ganglion  Cells. — Other  ganglion  cells  are  much 
larger  than  those  just  described.  They  possess  a  definite  cell- wall, 
and  have  one,  two,  or  more  long  processes  issuing  from  them. 
These  cells  are  called  stellate,  or  caudate  ganglion  cells  (Fig.  1, 1), 
according  to  their  form,  and  unipolar,  bipolar,  or  multipolar 
according  to  the  number  of  their  processes.  Each  cell  possesses 
a  large  oval  nucleus,  situated  near  its  centre.  The  nucleus  is 
composed  of  a  well-defined  membrane  and  an  intranuclear  net- 
work, and  its  centre  is  occupied  by  a  highly  refractive  nucleolus. 
The  body  of  the  cell  is  composed  of  numerous  minute  fibrils, 
which  are  connected  with  each  other  in  a  network. 

(3)  Processes. — The  processes  of  the  ganglion  cells  are  of  two 
kinds — branched  (Fig.  1, 1  y)  and  unbranched  (Fig.  1, 1  0).  The 
former  are,  like  the  body  of  the  ganglion  cells,  composed  of 
fibrils  which  run  in  a  longitudinal  direction,  and  pass  in  a  fan- 
like manner  from  the  processes  into  the  body  of  the  cell.  These 
processes  divide  and  subdivide  dichotomously,  so  as  to  form  a 
network  of  fine  filaments  (Fig.  1,  I  y).  The  unbranched  pro- 
cesses are  pale  and  finely  striated  bands,  which  represent  and 
are  continuous  with  the  axis  cylinder  of  the  medullated  nerve 
fibres.  The  unbranched  or  axis  cylinder  process  is  usually 
single,  although  occasionally  two  of  these  processes  are  attached 
to  one  cell.  Most  ganglion  cells,  and  especially  the  larger  ones, 
are  surrounded  by  a  pericellular,  or  lymph-space,  through  which 
the  processes  of  the  cell  pass.  The  capsule  in  which  the  gancr- 
lion  cell  is  enclosed  is  formed  of  a  hyaline  membrane  similar  to 
and  indeed  continuous  with  the  sheath  of  Schwann  of  the  nerve 
fibre.  This  capsule  is  lined  by  a  layer  of  small,  more  or  less 
polyhedral  or  flattened  protoplasmic  cells,  each  containing  a 
round  or  slightly  oval  nucleus,  and  forming  at  times  an  almost 
complete  epithelioid  lining  (Fig.  1,  II).     The  number  of  these 


20 


STRUCTUKE  AND  FUNCTIONS 

3  Fig.  1. 


Fig,  1  (from  Landois'  "Physiologie." ').—!,  Primitive  Fibrillffi.  2,  Axis  Cylinder. 
3,  Remak's  Fibres.  4,  MeduUated  Varicose  Fibres.  5,  6,  Medullated  Fibres, 
with  the  Sheath  of  Schwann ;  c,  Neurilemma ;  t,  t,  Ranvier's  Nodes ;  6, 
Medulla ;  d,  Cells  of  the  Endoneurium ;  a,  the  Axis  Cylinder ;  as,  Drop  of 
Myeline.  7,  Transverse  section  of  Nerve  Fibres,  with  distinct  Axis  Cylinder, 
Medullary  Sheath,  and  Perineurium ;  8,  Nerve  Fibres  treated  with  nitrate  of 
silver,  presenting  the  appearance  of  a  cross  at  the  Node.  I,  Multipolar  Ganglion 
Cell  of  the  Spinal  Cord  ;  z.  Axis  Cylinder  process  ;  y,  Protoplasmic  processes. 
On  the  right  of  I  a  Bipolar  G-anglion  Cell  is  represented.  II,  Peripheral 
Ganglion  Cell,  surrounded  by  a  Capsule  lined  by  Endothelial  Cells.  Ill, 
Ganglion  Cell,  with  Spirally-twisted  Fibre ;  m,  Capsule ;  n,  Axis  Cylinder 
process ;  o,  Spirally-twisted  Fibre. 

'  Landois  (L.).  Lehrbuch  der  Physiologie  des  menschen  einschliesslich  der 
Histologie  und  mikroscopischen  Anatomie.  Mit  besonderer  Beriicksicht  der 
prakt.  Medicin.    Wien,  1880.    s.  717. 


^ 


OF   THE  NEEVOUS   SYSTEM.  21 

lining  corpuscles  varies  in  different  ganglia,  and  they  are  most 
numerous  near  the  axis  cylinder.  The  hyaline  membrane  of 
the  capsule  is  continued  around  the  unbranched  process  of  the 
cell,  while  the  corpuscles  lining  the  capsular  membrane  also 
appear  at  intervals  as  nuclei  surrounded  by  a  thin  layer  of 
protoplasm  interposed  between  the  axis  cylinder  and  the 
sheath  of  Schwann,  and  between  the  latter  and  the  medullary 
sheath  when  once  the  fibre  has  become  medullated.  In  the  frog 
the  bipolar  ganglion  cells  of  the  abdominal  part  of  the  sympa- 
thetic system  are  very  peculiar,  inasmuch  as  one  process  becomes 
twisted  in  a  corkscrew  manner  round  another  process,  the 
former  being  called  the  spiral  {Fig.  1,  III  o)  and  the  latter  the 
straight  fibre  {Fig.  1,  III  ri).  These  cells  were  discovered  by 
Beale,^  and  are  consequently  named  after  him.  The  spiral  is 
generally  thinner  than  the  straight  fibre,  and  there  is  always  an 
accumulation  of  small  nuclei  where  it  leaves  the  cell  substance. 
The  spiral  fibre  is  at  first  thin,  but  soon  becomes  thicker  and 
transformed  into  a  medullated  nerve  fibre ;  but  the  straight  one 
remains  non-medullated.  Similar  cells  with  spiral  fibres  are 
met  with  in  mammals. 

§  14.  Nerve  Fibres  are  of  various  kinds,  and  often  of  complex 
composition. 

(1)  Elementary  Fibrils. — The  simplest  fibres  consist  of  very 
fine  fibrils  {Fig.  1,  1),  which,  in  the  fresh  condition,  as  well  as 
after  staining  with  chloride  of  gold,  present  minute,  more  or  less 
regular  varicosities.  These  fibrils  may  be  observed  in  the  ter- 
minal distribution  of  many  nerves,  as  the  stratum  of  the  optic 
fibres  in  the  retina  (Max  Schultze^),  and  the  terminal  dis- 
tribution of  the  olfactorius,  and  in  the  ultimate  distribution  of 
the  nerves  over  unstriped  muscular  fibres.  They  may  also  be 
observed  in  the  brain,  and  in  the  grey  substance  of  the  cord,  as 
the  finest  subdivisions  of  the  processes  of  the  ganglion  cells. 

(2)  Axis  Cylinder. — The  axis  cylinder  is  made  up  of  a  large 
number  of  elementary  fibrils,  arranged  longitudinally  {Fig.  1,  2). 
The  longitudinal  arrangement  of  the  fibrils  gives  to  the  axis 

^  Beale  (L.  S.).  "  New  Observations  upon  the  Structure  and  Functions  of  certain 
Nervous  Centres."    Microscopical  Journal,  Oct.,  1863. 

^  Schultze  (Max).  "  The  Retina."  Strieker's  Manual  of  Histology.  Translated 
by  Henry  Power,  M.D.     Syd.  Soc,  1873.    p.  218  et  seq. 


22  STRUCTURE  AND  FUNCTIONS 

cylinder  a  longitudinal  striation ;  while  minute  granules  are 
seen  between  these  which  appear  to  indicate  that  the  fibrils 
are  held  together  by  a  granular  cement-substance.  The 
unbranched  process  of  the  large  multipolar  ganglion  cells,  and 
which  from  its  continuity  with  the  axis  of  the  medullated  nerve 
fibres  has  been  called  the  axis  cylinder  process,  forms  the  most 
exquisite  example  of  a  naked  axis  cylinder  {Fig.  1,  I  z). 

(3)  Non-Medullated  Nerve  Fibres. — The  fibres  of  Remak 
{Fig.  1,  3)  consist  of  an  axis  cylinder  and  a  sheath,  which,  from 
its  discoverer,  has  been  called  the  sheath  of  Schwann.^  These 
fibres  are  also,  from  their  colour^  called  grey  fibres.  The  sheath 
of  Schwann  is  a  thin  hyaline  elastic  membrane,  and  its  internal 
surface  is  covered  at  regular  intervals  with  oval  nuclei.  These 
fibres  occur  in  the  sympathetic  system  of  nerves,  and  in  the 
olfactory  nerves ;  while  the  fibres  of  all  nerves  up  to  a  certain 
stage  of  embryonic  life  and  in  most  of  the  invertebrates  are  of 
this  variety.  The  sheath  of  Schwann  appears  to  be,  like  the 
sarcolemma  of  muscular  fibre,  hyaline  and  structureless ;  and, 
although  nuclei  are  scattered  on  its  internal  surface,  yet  they  do 
not  seem  to  belong  to  this  sheath,  but  to  be  independent 
structures,  and  the  precursors  of  the  next  complication  of  the 
nerve  fibre. 

(4)  Medullated  Fibres.  —  It  may  be  supposed  that  the 
development  of  the  non-medullated  into  the  medullated  fibres 
occurs  somewhat  in  the  following  manner  : — The  nucleus  on 
the  interior  of  the  sheath  of  Schwann  is  really  not  naked,  but 
is  surrounded  by  a  layer  of  protoplasm,  and  may  be  said  to 
represent  a  nucleated  cell.  Let  us  now  attend  to  the  changes 
which  occur  when  a  nucleated  cell  develops  into  a  fat  cell.  The 
oily  substance  collects  in  the  interior  of  the  protoplasm,  while 
the  outer  layer  of  the  latter  hardens  into  distinct  cell- 
membrane  ;  and,  as  the  oily  contents  accumulate,  the  nucleus 
is  pushed  towards  the  periphery,  and  the  protoplasm  is  stretched 
so  as  to  form  a  thin  layer  lining  the  interior  of  the  membrane. 
The  layer  of  protoplasm  becomes,  indeed,  so  thin  that  its 
presence  is  apt  to  be  overlooked.   Instead  of  ordinary  fat,  we  have 

*  Schwann  (Th.).  ^Microscopical  Researches  into  the  accordance  in  the  Structure 
and  Growth  of  Animals  and  Plants.  Translated  by  Henry  Smith.  Lond.,  1867. 
p.  142. 


OF  THE   NERVOUS  SYSTEM.  23 

only  to  suppose  that  a  fatty  material  of  very  special  character 
accumulates  in  the  interior  of  the  protoplasm,  surrounding  the 
nuclei  interposed  between  the  sheath  of  Schwann  and  the  axis 
cylinder,  in  order  to  account  for  the  development  of  the  medullated 
from  the  non-meduUated  fibres  (Ranvier^).  As  the  protoplasm 
which  surrounds  the  nucleus  becomes  distended  with  its  oily  con- 
tents, it  insinuates  itself  between  the  sheath  of  Schwann  and  the 
axis  cylinder;  and,  after  surrounding  the  latter,  the  free  margins 
of  the  cell  become  fused.  It  is  evident,  therefore,  the  axis 
cylinder  will  be  surrounded,  first,  by  a  membrane  and  a  thin 
layer  of  protoplasm,  then  by  a  more  or  less  thick  layer  of  oily 
material,  and  then  by  another  thin  layer  of  protoplasm  and  mem- 
brane, to  the  latter  of  which  will  be  attached  the  nucleus,  and  sur- 
rounding the  whole  will  be  the  structureless  sheath  of  Schwann. 
This  account  of  the  development  of  the  medullated  from  the  non- 
medullated  fibres  has  the  merit  of  giving  a  pretty  accurate 
account  of  the  appearances  presented  by  the  former.  Sur- 
rounding the  axis  cylinder,  which  has  been  already  described,  is 
the  medullary  sheath,  which  appears  as  a  thick,  sharply  out- 
lined, doubly-contoured,  fatty,  semi-fluid  substance  {Fig.  1,  6,  h). 
This  substance  coagulates  very  soon  after  death,  and  separates 
either  spontaneously  or  under  the  action  of  various  reagents  into 
smaller  or  larger  globular  drop-like  bodies  {Fig.  1,  x).  When 
treated  with  perosmic  acid,  the  medullary  substance  has  been  seen 
to  consist  of  longer  or  shorter  cylindrical  sections,  which  are  imbri- 
cated at  their  margins,  although  this  arrangement  is  not  observed 
in  all  fibres.  Each  of  these  sections  contains  a  reticulum,  in 
the  meshes  of  which  the  fatty  substance  is  embedded.  When 
the  reticulum  is  examined  from  the  surface  it  gives  a  honey- 
comb appearance  to  the  nerve ;  but  when  viewed  in  profile  it 
appears  composed  of  rod-like  elements,  which  are  the  septa  of 
the  honeycomb  seen  sideways.  A  narrow  space,  which  has  been 
called  the  periaxial  space,  has  been  observed  between  the  axis 
cylinder  and  the  medullary  sheath.  This  space  contains  fluid 
albuminous  cement  substance,  which  coagulates  under  the  action 
of  hardening  reagents,  and  then  forms  a  thin  granular  membrane 
surrounding  the  axis  cylinder. 

The  nucleus  surrounded  by  a  smaller  or  larger  film  of  proto-  • 

»  Eanvier  (L.).    Le9ons  sur  I'Histologie  du  Systeme  Nerveux.    Paris,  1878.    p.  113. 


24  STRUCTURE  AND   FUNCTIONS 

plasm  lies  embedded  on  the  outer  surface  of  the  medullary 
substance,  and  contains  an  intranuclear  reticulum  ;  while  the 
surrounding  protoplasm  often  contains  pigment  granules.  The 
nucleus  and  surrounding  protoplasm,  along  with  the  thin  film 
which  intervenes  between  the  sheath  of  Schwann  and  the 
medullary  substance,  represent  the  outer  wall  of  the  cell  from 
which  the  medullary  sheath  was  developed. 

(5)  Varicose  Fibres. — Some  medullated  nerve  fibres,  especially 
in  the  central  nervous  organs  and  optic  nerves,  present  more  or 
less  regular  varicose  thickenings  {Fig.  1,  4).  These  varicosities 
are  due  to  local  accumulations  of  albuminous  cement  substance 
in  the  periaxial  space,  and  not  to  a  coagulation  of  the  medullary 
sheath,  as  was  once  supposed. 

(6)  Ranvier's  Nodes.  —  If,  then,  the  medullary  sheath  is 
developed  from  the  cells  interposed  between  the  sheath  of 
Schwann  and  the  axis  cylinder,  it  becomes  interesting  to  enquire 
whether  any  trace  can  be  discovered  to  indicate  where  two 
adjoining  cells  meet.  The  annular  constrictions  which  appear 
at  regular  intervals  in  the  course  of  the  nerve,  and  which  were 
first  described  by  Ranvier,^  and  consequently  are  called  Ranvier's 
nodes  {Fig.  1,  8),  are  generally  accepted  as  proof  of  the  cellular 
origin  of  the  medullary  sheath.  Each  node  is  due  to  an  annular 
fold  of  the  sheath  of  Schwann  projecting  towards  the  axis 
cylinder;  while  there  is  an  interruption  of  the  medullary  sheath 
corresponding  to  each  constriction.  The  part  of  the  sheath 
between  each  constriction  is  called  an  interannular  segment, 
and  it  is  important  to  notice  that  each  of  these  segments 
possesses  one,  and  only  one,  nucleus,  which  is  situated  near  its 
middle  {Fig.  1,  6).  Ranvier  has  found  a  finely  granular  sub- 
stance in  the  concavity  of  the  constriction,  of  the  nature  of 
albuminous  cement  substance.  This  cement  substance  becomes 
deeply  stained  with  nitrate  of  silver,  which  also  penetrates  more 
or  less  deeply  into  the  interior  of  the  fibre  and  stains  the  cement 
substance  surrounding  the  axis  cylinder ;  so  that,  after  staining 
with  silver,  the  nerve  fibre  presents  a  peculiar  dark  cross  at  the 
node  {Fig.  1,  8),  the  longitudinal  branch  of  the  cross  appearing 

.  ^  Ranvier  (L.),  Contribution  a  I'histologie  et  ^  la  physiologie  des  nerfs  p^ri- 
ph^riques.  Comptes  Rendus.  Tome  LXXIII.,  1871,  p.  1,168.  Archiv,  de  Phy- 
siologie, 1872,  pp.  129  and  427. 


OF   THE  NERVOUS   SYSTEM.  25 

longer  or  shorter,  according  as  the  staining  has  extended  a 
greater  or  shorter  distance  on  the  surface  of  the  axis  cylinder. 
The  nodes  of  Ranvier  have  probably  an  important  function  to 
perform  with  respect  to  the  nutrition  of  the  fibre,  inasmuch  as 
they  permit  the  plasma  to  penetrate  more  freely  to  the  axis 
cylinder  than  could  possibly  take  place  if  the  medullary  sheath 
were  continuous. 

Some  medullated  nerve  fibres,  more  especially  efferent  fibres, 
subdivide  into  two  or  more  branches,  the  division  taking  place 
at  a  node  of  Ranvier. 

(7)  Connective  Tissue  Cells. —  Elongated  nuclei  may  be 
observed  lying  outside  the  sheath  of  Schwann  (Fig.  1,  6,  c^). 
They  are  the  nuclei  of  flattened  connective  tissue  cells  which 
are  formed  between  the  individual  nerve  fibres,  and  constitute 
the  cellular  portion  of  the  endoneurium.  In  isolated  fibres 
these  cells  form  a  continuous  endothelial  membrane  surrounding 
the  fibres  towards  their  terminal  distribution,  and  they  are 
closely  connected  with  the  lymph-spaces  of  the  endoneurium, 
which  will  be  subsequently  described, 

§  15.  Functions  of  Ganglion  Cells. — We  may  expect  that 
the  contrast  exhibited  in  the  structure  of  the  different  kinds  of 
ganglion  cells  is  paralleled  by  a  corresponding  contrast  in  their 
functions.  The  first  contrast  which  we  notice  is  that  of  size. 
It  is  evident  that  a  large  size  enables  the  cell  to  give  rise  to  a 
powerful  discharge  of  energy  ;  and  we  may  expect  that  the 
most  powerful  discharges  will  emanate  from  those  cells  which 
are  in  immediate  relation  with  the  outgoing  currents,  and  that 
the  smaller  cells  are  in  relation  with  the  incoming  currents, 
which  require  to  be  arranged  and  elaborated  before  being  re- 
flected outwards.  This  expectation  is  realised.  The  large  cells 
are  met  with  in  the  spinal  cord  in  connection  with  the  efferent 
and  the  small  cells  in  connection  with  the  afferent  nerve  fibres. 

The  next  contrast  between  the  spherical  and  the  caudate 
cells  is,  that  the  former  do  not  possess  a  definite  cell-wall,  and 
have  no  definite  connections  ;  while  the  latter  not  only  possess 
a  definite  cell-wall,  but  have  also,  by  means  of  their  processes, 
extremely  definite  connections  with  one  another  and  with  nerve 
fibres.     It  is  manifest,  therefore,  that  the  currents  through  the 


26  STRUCTURE  AND   FUNCTIONS 

former  must  pass  in  a  somewhat  diffused  manner,  while  in 
the  latter  they  will  pass  through  very  defined  channels.  The 
former,  then,  are  adapted  for  the  first  elaboration  of  the  in- 
cominof  currents,  and  the  latter  for  the  final  co-ordination  of  the 
outsfoinof  currents.  If  the  afferent  currents  are  few  in  number, 
and  if  they  are  at  the  same  time  well  organised  in  the  race, 
they  may  pass  more  or  less  directly  to  the  caudate,  without 
the  intervention  of  round  cells.  The  actions  to  which  the  in- 
ternal organs  are  subjected  are  uniform  in  kind,  and  relatively 
few  in  number.  The  stomach,  for  instance,  passes  through  the 
same  kind  of  actions  day  after  day  with  great  uniformity ;  its 
actions  are  also  thoroughly  organised  in  all  animals  ;  hence  the 
afferent  currents  from  it  to  the  sympathetic  ganglia  pass  directly 
into  bipolar  cells,  and  issue  from  these  as  efferent  currents.  The 
afferent  currents  ascending  from  the  feet  during  locomotion  are 
also  few  in  number,  simple  in  kind,  and  thoroughly  organised  in 
the  race,  and  it  is  probable  that  these  pass  from  the  afferent 
fibres  directly  to  the  large  motor  cells,  without  previously 
passing  through  the  small  round  cells  of  the  posterior  horns. 

The  next  contrast  I  shall  notice  is  one  existing  between  the 
caudate  cells  themselves.  Some  are  unipolar  or  bipolar,  and 
others  multipolar,  with  exceedingly  ramified  connections.  Some 
anatomists  doubt  the  existence  of  unipolar  cells ;  but  we  may 
expect  to  meet  with  the  bipolar  cells  where  the  co-ordinations 
to  be  effected  are  few  and  simple,  and  the  multipolar  where 
the  co-ordinations  are  numerous  and  complicated.  We  have 
already  noticed  that  the  movements  of  the  internal  organs  are 
comparatively  simple  and  uniform ;  and  it  is  mainly  in  the 
ganglionic  centres  which  preside  over  the  functions  of  those 
organs  that  the  bipolar  cells  are  found ;  while  the  best  examples 
of  the  multipolar  cells  are  found  in  the  anterior  horns  of  the 
cord  in  direct  relation  with  the  nerves  which  coavey  efferent 
impulses  to  the  organs  of  external  relation,  where  numerous 
and  complicated  movements  require  to  be  effected. 

The  order  of  the  development  of  the  nervous  system,  struc- 
turally regarded,  is  from  the  round  cell  without  membrane,  to 
the  caudate  cell  with  membrane ;  and  from  the  caudate  cell 
with  few  and  indeterminate  connections,  to  those  with  multiform 
and  defined  connections  :  just  as  the  order,  functionally  regarded, 


OF  THE   NERVOUS   SYSTEM.  27 

is  from  actions  which  are  diffused  and  simple,  to  those  which  are 
less  diffused  and  simple ;  and  from  the  latter,  to  those  which  are 
well  defined,  multiform,  and  complicated.  This  order  is  equally 
true,  whether  the  progress  of  development  is  contemplated  under 
the  aspect  of  the  transition  from  the  lower  to  the  higher  animals, 
or  from  the  initial  to  the  adult  stages  of  the  higher  animals ;  or 
under  the  aspect  of  the  process  known  as  education  in  the  higher 
animals. 

Ganglion  cells  contain  a  store  of  material  possessing  potential 
energy,  which,  on  the  application  of  a  liberating  force,  becomes 
kinetic.  The  liberating  force  which  renders  the  potential  energy 
kinetic  is  termed  a  stimulus.  The  chemical  process  which  under- 
lies the  transformation  is  probably  of  the  nature  of  oxidation, 
since  the  blood,  returning  from  the  brain,  for  instance,  is  as 
venous  as  that  returning  from  any  other  part  of  the  body ;  but 
we  possess  no  direct  evidence  of  the  nature  of  this  change.  In 
reference  to  the  liberating  force,  it  may  be  noticed  that  the 
ganglion  cells  do  not  appear  to  respond  to  the  usual  mechanical 
and  chemical  stimuli.  By  applying  strong  electrical  stimuli  to 
masses  of  ganglionic  cells,  such  as  those  of  the  cortical  part  of 
the  brain,  a  response  has  been  obtained  from  them  in  the  form 
of  muscular  movements.  These  cells  are,  however,  connected 
with  each  other  by  innumerable  fibres,  and  there  lie  imme- 
diately beneath  them  large  masses  of  nerve  fibres  to  which  the 
currents,  from  the  strength  employed,  must  be  conveyed ;  hence 
it  is  extremely  doubtful,  to  say  the  least,  how  far  the  muscular 
movements  in  such  a  case  can  be  taken  as  evidence  of  the  direct 
action  of  the  current  on  the  cells.  When  the  ganglion  cell  lies 
between  two  nerve  fibres,  as  those  engaged  in  reflex  action,  the 
potential  energy  of  the  cell  is  set  free  by  means  of  the  already 
liberated  energy  of  the  stimulated  fibre ;  and  the  energy  thus 
set  free  renders  kinetic  the  potential  energy  of  the  second  fibre. 
The  cell  largely  increases  the  amount  of  energy  rendered  kinetic 
during  the  action,  but  the  function  of  the  cell  in  this  case  does 
not  greatly  differ,  except  in  degree,  from  that  of  a  nerve  fibre. 
But  even  in  such  a  simple  case  the  cell  generally  becomes  the 
point  of  union  of  several  fibres,  and  thus  it  helps  to  direct  the 
disturbance  it  receives  through  one  fibre  into  two  or  more  fibres, 
and  becomes  the  active  agent  in  giving  a  new  direction  to  the 
current. 


28  STRUCTURE  AND  FUNCTIONS 

The  manner  in  which  the  energy  of  the  cells  is  liberated  in 
automatic  action  is  not  easy  to  understand.  It  is  probable  that 
a  great  many  of  the  actions  regarded  as  automatic  are  of  reflex 
origin.  There  is  another  way  in  which  the  energy  of  the  auto- 
rnatic  cell  may  be  supposed  to  be  liberated.  The  energy  set 
free  during  one  moment  may  perform  the  part  of  a  liberating 
force  the  next  moment  on  the  store  of  potential  energy,  which  is 
being  constantly  replenished  from  the  blood,  just  as  a  fire,  when 
once  kindled,  may  be  kept  burning  if  supplied  with  combustible 
material.  But  the  liberation  of  energy  effected  by  this  means 
would  be  continuous;  while  the  liberation  of  energy  in  a  stimu- 
lated nerve  fibre  is  interrupted  or  intermittent.  It  is  quite 
possible,  however,  for  a  continuous  liberation  in  a  ganglion  cell 
to  give  rise  to  an  interrupted  or  rhythmical  stimulation  of  a  nerve 
fibre.  Suppose  that  the  energy  liberated  in  the  cell  has  to  over- 
come a  certain  resistance  before  acting  as  a  stimulus  on  a  nerve 
fibre,  a  certain  tension  must  be  reached  prior  to  stimulation; 
and  when  the  requisite  tension  is  reached,  a  discharge  takes  place 
through  the  nerve.  This  discharge  diminishes  for  a  time  the 
tension  of  the  energy  liberated  in  the  cell ;  and,  as  it  is  probable 
that  the  molecules  of  the  axis  cylinder  have  fallen  during  the 
discharge  from  an  unstable  to  a  stable  equilibrium,  the  resistance 
to  a  second  discharge  through  the  fibre  will  be  increased.  The 
continuous  liberation  of  energy  within  the  cell  soon  raises  the 
tension  again;  while  by  restorative  processes  in  the  axis  cylinder 
its  molecules  are  once  more  replaced  in  their  position  of  unstable 
equilibrium,  and  the  conditions  for  a  second  discharge  are  quickly 
restored,  to  be  again  succeeded  by  the  conditions  of  a  second 
interval.  When  the  resistance  is  great  it  will  require  a  high 
tension  to  overcome  it,  and  this  implies  that  the  liberation  of 
energy  must  continue  for  a  long  time  before  the  necessary  degree 
of  tension  is  reached,  and  that  when  the  discharge  takes  place  it 
will  be  a  powerful  one.  Strength  of  discharge,  then,  involves 
length  of  interval  between  the  discharges ;  or,  in  other  words, 
the  strength  of  every  discharge  of  energy  through  a  nerve  is 
inversely  proportional  to  its  frequency. 

§  16.  Functions  of  Nerve  Fibres. — The  axis  cylinder,  or  more 
properly  the  elementary  fibril,  is  the  essential  constituent  of  the 


^ 


OF  THE   NERVOUS   SYSTEM.  29 

nerve  fibre,  and  has  been  aptly  compared  to  the  core  of  copper 
wire  strands  in  a  submarine  telegraph  cable.  The  next  most 
important  constituent  is  the  primitive  sheath,  which  has  been 
compared  to  the  outer  coating  of  rope  of  the  cable.  The  last 
constituent,  and  therefore  that  which  distinguishes  the  most 
highly  differentiated  fibre,  is  the  medullary  sheath,  which  has 
been  compared  to  the  layer  of  gutta-percha  in  a  telegraph 
cable. 

Glancing  now  at  these  three  kinds  of  fibres,  the  most  notice- 
able feature  is,  that  all  of  them  are  adapted  for  conveying  im- 
pulses in  the  direction  of  their  length ;  but  when  several  of  the 
fibres  of  Remak  are  arranged  side  by  side,  free  lateral  diffusion 
of  the  currents  will  take  place,  while  the  primitive  sheath  of  the 
non-medullated  fibres  will  check  this  diffusion  to  a  considerable 
extent,  and  it  will  be  entirely  prevented  by  the  medullary 
sheath  of  the  medullated  fibres.  We  may  expect,  therefore, 
to  find  the  first  order  of  fibre  when  the  function  is  of  a  very 
diffused  character,  the  second  when  the  function  is  less  diffused, 
and  the  third  when  it  is  very  defined,  and  when,  consequently, 
any  lateral  diffusion,  or  irradiation,  as  it  is  called,  would  mar  the 
effect.  The  fibres  of  Remak  are  mainly  found  in  the  intra- 
cranial portion  of  the  olfactory  nerve ;  and  it  is  well  known  that, 
of  all  the  special  senses,  the  olfactory  is  the  most  diffused.  The 
non-medullated  fibres  are  met  with  in  the  sympathetic  nerves, 
which  preside  over  the  actions  of  the  organs  of  internal  rela- 
tion—actions which  are  much  more  diffused  than  those  of  the 
organs  of  external  relation ;  while  the  medullated  fibres  alone  are 
fitted  to  preside  over  the  definite  actions  of  the  latter  organs. 
Any  lateral  diffusion  of  the  nerve  currents  would  entirely  mar 
the  definite  and  delicate  movements  of  the  hand  required  for 
writing ;  while  some  degree  of  this  diffusion  would  appear  to  be 
necessary  for  that  continuous  and  diffused  contraction  of  the 
muscular  coat  of  the  bowels  which  causes  peristalsis. 

Nerve  fibres  exist  in  the»conditions  of  rest,  activity,  and  death. 
In  passing  from  one  state  to  another  their  physical  properties 
undergo  no  perceptible  change  such  as  takes  place  in  muscle; 
hence  these  different  conditions  cannot  be  distinguished  from 
each  other  in  nerve  by  simple  inspection.  A  nerve  is  living  if  it 
possess  irritability.     The  agents  which  evoke  the  activity  of 


30  STRUCTURE  AND  FUNCTIONS 

a  nerve  fibre  are,  as  in  the  case  of  the  ganglion  cells,  termed 
stimulants;  while  the  property  which  nerve  fibres  possess  of 
transmitting  the  state  of  activity  from  one  point  to  the  next,  is 
called  their  conductivity.  When  the  irritability  is  not  called 
into  activity  by  any  stimulus,  the  nerve  is  at  rest.  No  doubt  a 
certain  amount  of  material  exchange  takes  place  in  a  nerve,  as 
in  other  tissues,  during  a  state  of  repose ;  but  as  nerves  are 
almost  destitute  of  blood-vessels,  the  material  exchanges  which 
take  place  in  them  must  be  slight.  When  the  nerve  fibre  gives 
evidence  of  evolving  energy  when  acted  on  by  a  stimulus,  it  is  in 
an  active  condition;  and  when  it  gives  no  response  to  the  action 
of  a  stimulus,  it  is  dead.  Death  of  nerve  tissue  is  also  recognised 
by  the  appearance  of  an  acid  reaction,  and  by  certain  electro- 
motor phenomena  as  well  as  by  the  loss  of  irritability. 

(i.)  Irritability. — The  laws. of  irritability  have  already  been 
considered  in  a  general  way ;  but  we  must  now  establish  empiri- 
cally the  laws  which  influence  the  degree  of  nerve  irritability. 

(1)  Continued  inaction  of  a  nerve  diminishes  and  finally 
destroys  its  irritability,  and  leads  at  last  to  fatty  degeneration. 
It  is  very  probable  that  the  first  effect  of  inaction  is  to  increase 
the  irritability. 

(2)  The  irritability  of  a  nerve,  after  it  ceases  to  be  connected 
with  a  living  central  organ,  increases  considerably  at  first,  but 
afterwards  diminishes,  and  finally  disappears.  When  the  separa- 
tion is  effected  by  transverse  section,  the  process  is  accelerated, 
and  it  also  takes  place  more  quickly  in  the  central  than  in  the 
peripheral  part  of  the  nerve.  In  this  case,  some  part  of  the  effect 
is  no  doubt  due  to  the  mechanical  stimulus  of  the  section.  If  the 
cut  nerve  be  allowed  to  remain  in  the  body,  it  undergoes  fatty 
degeneration.  But  if  the  cut  ends  be  kept  in  apposition,  they 
grow  together  after  a  time,  and  they  have  even  been  known 
to  grow  together  when  the  cut  ends  were  half  an  inch  or  more 
apart. 

(3)  Gentle  stimulation  of  a  nerve  increases  its  irritability ; 
over-stimulation  diminishes  it,  and  may  destroy  it  at  once 
(shock).  Continued  activity  diminishes  the  irritability,  and  may 
gradually  destroy  it  (exhaustion). 

(4)  Mechanical  irritants,  such  as  crushing  or  pinching,  destroy 
the  irritability.     If  the  mechanical  stimulus,  however,  is  not  too 


OF  THE  NERVOUS   SYSTEM.  31 

violent,  the  irritability  is  first  increased,  as  occurs  after  section  of 
a  nerve  with  a  sharp  knife. 

(5)  A  decided  disturbance  of  chemical  composition,  such  as  is 
caused  by  desiccation  and  treatment  with  strong  alkalies  or  acids, 
destroys  the  irritability.  Certain  agents  absorbed  into  the  blood, 
such  as  strychnia,  first  increase  and  then  destroy  the  irritability 
of  certain  nerve  fibres,  and  probably  also  of  some  ganglion  cells. 
Curara  lowers  the  irritability  of  the  peripheral  terminations  of 
voluntary  motor  nerves ;  but  Bernard  found  that  a  moderate 
dose  first  increases  the  irritability,  which  then  becomes  diminished 
and  ultimately  lost. 

(6)  The  state  of  the  nutrition  of  a  nerve  has  a  great  effect  on 
its  irritability.  If  the  nutrition  is  wholly  arrested,  the  irritability 
disappears.  But  a  nerve  whose  nutrition  is  merely  defective 
discharges  its  energy  more  readily  than  one  whose  nutrition  is 
perfect. 

(7)  Gradual  withdrawal  of  heat  diminishes,  and  gradual  addi- 
tion of  heat  (within  certain  limits)  increases,  the  irritability. 
Too  much  heat  lowers  and  may  instantly  annihilate  it  by 
inducing  chemical  change. 

(8)  If  a  constant  galvanic  current  be  passed  through  a  portion 
of  a  nerve,  it  acts  as  a  stimulus  at  the  moment  of  making  and 
breaking  contact.  When  the  current  is  passing  through  the 
nerve,  the  latter  appears  to  be  at  rest,  but  its  irritability  is 
profoundly  affected.  This  condition  is  called  electrotonus  or  the 
electrotonic  condition,  but  it  would  serve  no  useful  purpose  to 
enter  on  its  consideration  here. 

(ii.)  Conduction. — A  particular  nerve  fibre  usually  transmits 
its  activity  in  one  direction  only — hence  the  distinction  made 
between  afferent  and  efferent  fibres  ;  but  several  circumstances 
might  be  mentioned  which  tend  to  prove  that  a  nerve  fibre  can 
conduct  in  both  directions.  It  has  been  proved  by  experiment, 
that  if  a  purely  afferent  nerve  (gustatory)  be  divided,  and  its 
central  end  be  made  to  unite  with  the  distal  end  of  a  divided 
motor  nerve  (hypoglossal),  irritation  of  the  former  after  the  parts 
have  been  healed  produces  contraction  in  the  muscles  supplied 
by  the  latter.^ 

Continuity  of  the  nerve  fibre,  especially  of  the  axis  cylinder,  is 

'  Philippeaux  et  Vulpian.    M^moires  de  la  Soci^t^  de  Biologic,  1859,  p.  384. 


32  STRUCTUEE  AND  FUNCTIONS 

necessary  for  conduction.  Lesions  of  the  fibre  from  section  or 
caustic,  or  even  from  a  certain  amount  of  pressure,  interrupt 
conduction. 

The  transmission  of  the  active  condition  from  one  end  of  a 
nerve  fibre  to  another  occupies  time.  The  average  rate  of  con- 
duction in  human  motor  nerves  is  found  by  experiment  to  be 
111  feet,  or  33  metres  per  second;  and  in  the  sensory  nerves  to 
be  140  feet,  or  about  42  metres  per  second.^ 

The  velocity  with  which  nerve  energy  travels  may  be  increased 
or  diminished.  The  rule  is  that  cold,  the  condition  of  anelectro- 
tonus,  and  all  conditions  which  lower  the  irritability,  diminish 
the  velocity  ;  while  heat,  the  condition  of  catelectrotonus,  and  all 
conditions  which  raise  the  irritability,  increase  the  velocity  of 
conduction. 

Pfluger  observed  that  the  effect  of  stimulating  a  motor  nerve 
is  so  much  the  greater  the  further  removed  the  point  of  stimula- 
tion is  from  the  muscle.  He  explained  this  effect  by  supposing 
that  the  active  condition  of  a  nerve  accumulates  strength  in 
transmission,  like  the  momentum  of  a  falling  mass,  as  an 
avalanche.  It  is  now  considered  more  probable  that  this 
phenomenon  depends  upon  the  increased  irritability  of  the  more 
distant  parts  of  the  nerve  caused  by  section. 

(iii.)  Stimuli. — All  mechanical  impressions,  as  blows,  pressure, 
section,  etc.,  which  cause  alterations  of  the  form  of  a  portion  of 
a  nerve,  act  as  stimuli  while  producing  the  change.  Irritability 
and  conductivity  are  destroyed  if  the  nerve  has  been  permanently 
injured.  Agents  which  alter  the  chemical  constitution  of  a 
nerve  with  a  certain  degree  of  rapidity,  act  as  stimuli.  Some 
substances,  as  ammonia  and  solutions  of  metallic  salts,  produce 
death  so  rapidly  that  the  development  of  the  stimulating  effect 
is  prevented.  A  sudden  rise  of  temperature  in  a  nerve  also  acts 
as  a  stimulus  and  causes  the  nerve  to  discharge  its  energy. 

Variations  in  the  intensity  of  an  electric  current  stimulate 
nerve  fibres,  the  stimulation  being  the  more  powerful  the  more 
suddenly  variations  occur.  The  variation  generally  employed  is 
that  produced  by  making  or  breaking  a  current  through  the 
nerve ;   but  a  sudden  increase  or  diminution  in  the  strength 

»  Rutherford  (Prof.  W.).  "  Lectures  on  Experimental  Physiology."  The 
Lancet.    Vol.  I.,  1871,  p.  437. 


OF   THE  NERVOUS   SYSTEM.  33 

of  a  current  also  acts  as  a  stimulus.  The  shocks  of  frictional 
electricity  have  a  very  powerful  stimulating  effect,  since  the 
currents  it  forms  are  extremely  rapid  in  their  appearance  and 
disappearance. 

§  17.  General  Theory  of  Nerve  Functions. — These,  then,  are 
some  of  the  more  important  empirical  laws  of  the  functions  of 
nerve  fibres,  and  of  the  mode  of  operation  of  those  agents  which 
evoke  their  activities.  Let  us  now  endeavour  to  reduce  these 
laws  to  some  degree  of  order.  On  comparing  them  with  one 
another,  the  most  obvious  relation  which  exists  between  them 
is — that  the  mechanical,  chemical,  and  thermal  agents  which 
act  as  stimuli  when  suddenly  applied  to  a  nerve,  increase  the 
irritability  when  gradually  applied  and  in  a  moderate  degree  of 
intensity,  and  destroy  it  when  suddenly  applied  beyond  a  certain 
degree  of  intensity ;  and  it  has  just  been  seen  that  all  con- 
ditions which  increase  the  irritability  of  the  nerve  also  increase 
the  velocity  of  conduction.  Such  are  the  facts  which  require 
explanation. 

All  the  functions  of  nerve  fibres  are  closely  connected  with 
the  fundamental  property  of  irritability.  We  have  already 
seen  that  irritability  depends  upon  the  molecules  of  the  proto- 
plasm being  in  a  condition  of  unstable  equilibrium,  and  that 
the  energy  is  rendered  actual  when  the  molecules  fall  to  a 
relatively  stable  position.  There  can  be  little  doubt  that 
nerve  irritability  depends  upon  the  protoplasm  of  the  axis 
cylinder  being  composed  of  molecules  in  unstable  positions, 
and  that  these  are  so  connected  that  the  movement  or 
alteration  of  one  leads  to  the  movement  or  alteration  of  those 
in  the  immediate  neighbourhood.  The  true  nature  of  this 
movement  is  not  known,  but  the  theory  most  consistent  with 
facts  assumes  that  it  is  a  chemical  change,  either  of  the 
nature  called  isomeric,  or  an  oxidation,  such  as  occurs  when 
a  train  of  gunpowder  is  ignited  at  one  end.  The  hypothesis 
advanced  by  Mr.  Herbert  Spencer^  affords  probably  the  best 
explanation  of  the  phenomena.     He  believes  that  the  change 

1  Spencer  (Mr.  Herbert).  The  Principles  of  Psychology.  Vol.  I.,  p.  21.  See 
also  Huxley  (T.  H.).  "  Sensation  and  the  Senaiferous  Organs."  Science  and 
Culture.     Lond.,  1881.     p.  251. 

VOL.  I.  D 


34  STRUCTUEE  AND   FUNCTIONS 

in  a  nerve  cell  during  activity  is  of  the  nature  of  a  chemical 
decomposition,  and  that  of  a  nerve  fibre  of  an  isomeric  trans- 
formation. The  slow  rate  at  -which  the  energy  travels  from 
one  end  of  a  nerve  to  another,  in  comparison  with  the  speed 
of  electric  currents,  shows  that  these  two  kinds  of  energy  must 
differ  essentially.  The  agents  which  act  as  stimuli  set  up  this 
chemical  change  at  one  end  of  a  nerve,  and  this  is  slowly  propa- 
gated to  the  other  end.  When  these  agents  are  gradually 
applied,  they  act  by  placing  the  molecules  in  more  unstable 
positions  without  causing  them  to  move  towards  one  another,  so 
that  a  slighter  degree  of  stimulus  will  subsequently  induce  the 
necessary  chemical  change ;  while  the  same  agents,  when  sud- 
denly applied  in  high  intensity,  will  produce  such  a  large  amount 
of  chemical  change  as  to  destroy  the  irritability.  The  following 
illustration  may  enable  us  to  some  extent  to  realise  what  occurs 
in  a  nerve  fibre  during  the  transmission  of  its  energy.  We  have 
seen  that  when  matter  possesses  potential  energy,  a  certain  force 
called  the  liberating  force  is  necessary  in  order  to  render  the 
energy  actual ;  or,  in  other  words,  matter  under  those  conditions 
offers  a  certain  amount  of  resistance  to  change,  and  the  higher 
the  resistance  the  stronger  must  be  the  liberating  force.  Suppose 
two  books,  each  a  foot  in  height,  to  be  standing  on  end  on  a 
table,  and  that  the  one  is  half  an  inch  and  the  other  two  inches 
in  thickness  ;  the  slightest  tap  on  the  free  end  of  the  first  will 
cause  it  to  fall,  while  it  will  require  a  considerable  blow  to  cause 
the  second  to  fall.  The  resistance  which  the  latter  offers  to 
change  is  greater  than  that  of  the  former.  And  if  we  arrange 
two  rows  of  these  books  placed  on  end  at  convenient  distances,  in 
such  a  way  that  when  the  first  book  of  a  row  is  made  to  fall  it 
will  strike  the  second  and  cause  it  to  fall  towards  the  third,  and 
so  on  till  the  row  has  fallen  with  the  books  overlapping  each 
other,  it  will  at  once  be  noticed  that  the  row  made  up  of  the  thin 
books  falls  much  sooner  than  that  made  up  of  the  thick  books. 
Each  book  of  the  latter  row  offers  a  greater  resistance  to  change, 
and  not  only  is  a  greater  force  necessary  to  initiate  the  movement 
in  the  first  book  of  the  row,  but  the  transmission  of  the  move- 
ment from  one  end  to  the  other  is  delayed.  When  the  molecules 
of  the  axis  cylinders  occupy  relatively  stable  positions,  the  irri- 
tability of  the  nerve  fibres  is  depressed,  a  greater  resistance  is 


^ 


OF  THE  NERVOUS   SYSTEM.  35 

offered  to  change,  and  a  stronger  stimulus  naust  be  applied  to 
them  in  order  to  awaken  their  activities.  But  not  only  must  the 
initial  liberating  force  be  stronger,  but  it  must  be  stronger  at 
each  point  of  the  conduction — hence  the  velocity  of  the  con- 
duction will  be  rendered  slower ;  while  the  converse  obtains 
when  the  irritability  is  increased. 

§  18.  Construction  of  the  Nervous  Tissues. — It  has  been  seen 
that  on  ultimate  analysis  the  nervous  tissues  consist  of  cells  and 
fibres,  and  we  must  now  trace  the  relative  positions  occupied  by 
these  elements  in  the  construction  of  the  tissues.  The  general 
law  of  organisation  is  that  unlike  functions  entail  unlike  struc- 
tures ;  and  inversely,  that  unlike  parts  .assume  activities  of 
unlike  kinds.  On  looking  at  a  simple  nervous  system,  the 
greatest  contrast  in  structure  is  shown  between  certain  knots 
termed  ganglia  and  certain  cords  termed  nerves,  which  connect 
one  ganglion  with  another,  or  with  different  parts  of  the  orga- 
nism. Since  these  parts  exhibit  the  widest  structural  contrast 
existing  in  the  nervous  system,  they  will  also  exhibit  the  widest 
functional  contrast.  The  ganglia  are  composed  of  nerve  cells 
with  thin  connecting  processes,  held  together  by  a  fine  con- 
nective tissue  ;  whilst  the  nerves  are  composed  of  nerve  fibres 
arranged  side  by  side  in  a  bundle,  also  held  together  by  a  firm 
connective  tissue,  and  the  whole  surrounded  by  a  fibrous  sheath. 
Functionally  regarded,  the  ganglia  are  originators  of  motion,  and 
to  some  extent  conductors  also,  while  the  nerves  are  mainly 
conductors,  although  it  is  probable  that  they  also  are  in  some 
small  degree  originators  of  motion. 

In  the  principal  nervous  centres  of  the  higher  animals,  how- 
ever, the  ganglia,  instead  of  forming  knots,  have  come  by  approxi- 
mation and  fusion  to  form  a  continuous  mass,  which  from  its 
colour  is  called  the  grey  substance  ;  and  the  conducting  fibres, 
instead  of  forming  cords  connecting  two  separate  ganglia,  also 
form  a  continuous  mass,  which  from  its  colour  is  called  the  white 
substance.  But,  besides  the  central  organs  and  the  conducting 
apparatus,  we  must  distinguish  in  a  nervous  system  the  peripheral 
terminations  of  the  conducting  apparatus — terminations  which 
are  specially  adapted  on  the  one  hand  for  receiving  impressions 
from  environing  agents  and  objects,  and  on  the  other  for  trans- 


36  STRUCTURE  AND   FUNCTIONS 

muting  the  molecular  motions  of  the  nervous  system  into  the 
molecular  motions  of  the  work-organs.  It  is  not  intended  to 
enter  upon  even  the  most  general  consideration  of  the  peripheral 
terminations  of  the  conducting  apparatus  ;  hence  our  subsequent 
remarks  will  be  confined  to  the  consideration  of  the  conducting 
apparatus  itself,  and  to  the  central  end-organs  of  this  apparatus. 

The  conducting  apparatus,  as  already  pointed  out,  consists  of 
cords  called  nerves,  and  continuous  masses  called  the  white 
substance,  both  of  these  being  composed  of  nerve  fibres,  which 
usually  remain  unbranched  in  their  whole  course.  Nerve  fibres 
are  grouped  into  three  classes  with  reference  to  the  direction 
in  which  the  energy  passes  through  them — (I.)  Afferent  fibres, 
or  those  which  convey  impressions  from  the  periphery  to  a 
nerve  centre ;  (II.)  Efferent,  or  those  which  convey  impulses 
from  a  nerve  centre  to  a  work-organ  ;  and  (III.)  Intercentral,  or 
those  which  conduct  between  two  nerve  centres. 

(i.)  Afferent  Fibres. — I.  The  afferent  fibres  are  further  sub- 
divided into — (1)  those  which  minister  to  reflex  action,  that  is, 
those  in  which  the  disturbances,  conveyed  by  an  afferent  nerve 
to  a  centre,  are  immediately  transferred  to  efferent  nerves ;  (2) 
sensory  nerves,  or  those  which  convey  impressions  from  the 
periphery  destined  to  reach  the  highest  nervous  centre,  which 
we  shall  subsequently  see  to  be  the  organ  of  mind  (they  are 
called  sensory,  because  any  disturbance  of  them  produces  a 
sensation) ;  and  (3)  inhibitory  nerves,  or  those  which  restrain 
action.  It  is  generally  assumed  that  there  are  three  distinct 
kinds  of  nerve  fibres,  corresponding  to  these  three  functions  ;  but 
this  is  an  assumption  which  is  by  no  means  proved  as  yet.  The 
same  system  of  afferent  fibres  may  minister  to  the  sensory  and 
reflex  functions,  and  it  may  depend  upon  various  other  circum- 
stances, such  as  the  relative  resistance  which  the  intercentral 
fibres  concerned  in  the  operation  offer  tp  the  conduction  of 
the  impression,  whether  one  or  other  action,  or  both  of  them, 
will  ensue.  The  balance  of  evidence,  however,  appears  to 
be  in  favour  of  the  view  that  distinct  fibres  exist  for  these 
functions.  But  the  existence  of  inhibitory  nerves  is  very 
doubtful.  No  one  doubts  the  existence  of  an  inhibitory  function  ; 
the  only  question  which  arises  is,  whether  the  function  is  simple 
or  compound.     If  the  function  is  simple,  there  will  be  special 


OF  THE  NERVOUS   SYSTEM.  37 

fibres  to  minister  to  it;  but  if  it  is  compound,  it  will  be  a  resultant 
of  the  action  of  nerve  fibres,  or  of  nerve  fibres  and  cells  engaged  in 
other  operations.  For  instance,  I  throw  the  flexors  of  my  leg 
and  thigh  into  a  state  of  rigid  contraction,  yet  there  is  no  move- 
ment of  my  leg,  because  I  have  at  the  same  time  thrown  the 
extensors  into  contraction.  The  one  action  counteracts  the 
other,  and  the  leg  is  kept  in  a  state  of  rest  ;  but  although  the 
nerves  which  supply  the  extensors  have  been  made  to  perform 
an  inhibitory  function,  there  are  no  special  inhibitory  nerve 
fibres  concerned  in  the  action.  But  let  us  take  an  example  from 
a  more  purely  inhibitory  function. 

If  the  central  end  of  the  superior  laryngeal  nerve  after  section 
be  stimulated  by  a  gentle  interrupted  current,  the  respiratory 
rhythm  is  rendered  slow,  or  stopped  altogether  in  a  state  of 
expiration ;  while,  if  the  central  stump  of  one  of  the  divided  vagi 
be  stimulated,  the  respiration,  which  from  the  division  of  the 
nerves  had  become  slow,  is  quickened  again.  If  the  nerve  has 
become  exhausted  by  previous  stimulation,  further  stimulation 
of  the  main  trunk  may  cause  the  respiration  to  become  slower, 
or  even  to  stop.  In  accordance  with  these  facts  it  is  generally 
supposed  that  the  superior  laryngeal  branch  of  the  vagus  contains 
inhibitory  fibres,  while  the  main  trunk  contains  both  accelerating 
and  inhibitory  fibres,  the  former  of  which  largely  predominate. 
It  is  very  doubtful,  however,  whether  there  is  any  necessity  to 
assume  the  existence  of  any  fibres  except  the  afferent  fibres 
engaged  in  ordinary  reflex  action.  The  afferent  impulses  are 
first  conveyed  to  an  automatic  respiratory  centre  in  the  medulla 
oblongata,  a  centre  which  possesses  a  rhythmic  action  whereby 
it  emits  complex  co-ordinated  impulses  of  inspiration  and  expira- 
tion. The  afferent  disturbances  brought  to  this  centre  by  the 
pneumogastrics  modify  its  regulative  impulses  according  to  the 
requirements  of  the  system.  When,  however,  the  afferent  fibres 
are  stimulated  by  a  faradic  current,  the  rhythm  of  the  molecular 
disturbances  conveyed  by  them  may  be  so  out  of  relation  to  the 
rhythm  of  the  automatic  centre,  that  fibres,  which  usually  excite 
the  centre,  may  now  arrest  its  action.  It  is  well  known  that  two 
strings  may  be  arranged  in  such  a  manner  that  each  will  produce 
a  musical  note  when  made  to  vibrate  separately ;  that  they  may 
under  one  set  of  circumstances  produce  musical  notes,  which 


38  STRUCTUEE  AND  FUNCTIONS 

harmonise  with  one  another,  and  under  slightly  dififerent  circum- 
stances produce,  not  musical  notes,  but  a  succession  of  beats  with 
intervening  periods  of  silence.  It  is  quite  possible,  therefore, 
that  the  different  effects  obtained  by  stimulating  the  central  ends 
of  the  divided  vagi  and  their  branches  may  arise  from  the  altered 
rhythm  of  the  afferent  impulses  acting  upon  an  automatic  centre 
already  engaged  in  action. 

But  the  most  remarkable  instance  of  inhibition  is  offered 
by  the  heart.  It  is  found  that  if  the  peripheral  portion  of  a 
divided  pneumogastric  nerve  be  stimulated  for  even  a  short 
time  by  a  faradic  current,  the  heart  is  immediately  brought 
to  a  standstill,  with  its  cavities  flaccid  and  dilated.  Here  it 
is  assumed  that  the  pneumogastric  contains  cardio-inhibitory 
efferent  fibres.  There  are  good  grounds  for  believing,  however, 
that  the  fibres  of  the  pneumogastrics  which  eod  in  the  heart 
terminate  in  local  automatic  ganglia ;  and  therefore  these  fibres 
must  be  regarded  as  intercentral,  and  not  as  true  efferent  fibres. 
Hence  the  cardio-inhibitory  action  of  the  pneumogastric  is  sus- 
ceptible of  the  same  explanation  which  has  been  given  of  the 
respiratory  inhibitory  action — namely,  that  the  action  of  the 
automatic  ganglia  is  arrested  by  the  loss  of  harmony  between 
the  rhythm  of  their  action  and  the  rhythm  of  the  impulses 
conveyed  to  them  by  the  artificially  stimulated  nerve.  This 
explanation  is  much  strengthened  by  the  fact  discovered  by 
M.  Onimus,^  that  by  duly  regulating  the  rhythm  of  the  galvanic 
shocks  passed  through  the  nerve  in  correspondence  with  the 
cardiac  rhythm  he  could  increase  the  number  and  power  of  the 
cardiac  beats.  The  influence  of  the  vaso-motor  nerves  in  causing 
dilatation  of  the  minute  arteries  is  another  striking  instance  of 
an  inhibitory  action.  The  general  law,  as  discovered  by  Ludwig 
and  Loven,  is  that  when  an  afferent  nerve  is  stimulated  there  is 
reflected  to  the  part,  along  its  vaso-motor  nerves,  an  influence 
by  which  its  minute  arteries  are  suddenly  dilated ;  while  an 
influence  is  sent  to  every  other  part  of  the  body,  which  slightly 
contracts  the  arteries  supplying  them.  There  are  good  grounds 
for  believing  that  arterial  tone  is  maintained  by  local  peripheral 
nervous  mechanisms  present  in  or  near  the  small  arteries,  which 

1  Onimus.     "  Experiences  sur  le  pneumogastrique  et  sur  les  nerfs  pr€tendus 

V^r.y.&i-   "        n,^Tn-r>foo   T?onrlna  Tnmo  T.'VXXTTT  Pn.Hs.    1S7(l.        tl.    OSS. 


OF  THE  NERVOUS  SYSTEM.  39 

are  connected  by  intercentral  fibres  with  the  central  mechanism 
in  the  cord.  The  function  of  these  mechanisms,  like  the  functions 
of  the  local  automatic  ganglia  of  the  heart,  may  be  stimulated 
or  arrested  according  as  the  rhythm  of  the  impulses  conveyed 
to  them  from  the  centres  in  the  cord  are  in  harmony  or  out 
of  harmony  with  tbe  rhythm  of  their  own  actions.  Loss  of 
arterial  tone,  therefore,  does  not  require  us  to  postulate  the 
existence  of  special  inhibitory  fibres.  Everyone  is  conscious  of 
being  able  by  an  effort  of  the  will  to  stop  reflex  movements ; 
and  when  the  brain  of  a  frog  is  removed,  reflex  actions  are 
developed  to  a  much  greater  degree  than  in  the  perfect  animal. 
If  the  optic  lobes  of  a  frog  from  which  the  cerebral  hemispheres 
have  been  removed  be  stimulated  by  placing  upon  them  a 
crystal  of  sodium  chloride,  it  will  be  found  that  the  generation 
of  reflex  impulses  in  the  spinal  cord  is  greatly  interfered  with — 
that  is,  the  stimulation  of  the  optic  lobes  has  inhibited  the 
reflex  action  of  the  cord.-^  From  these  experiments  it  has  been 
assumed  that  specific  inhibitory  centres  exist  in  the  optic  lobes. 
But  this  assumption  is  by  no  means  warranted  by  the  facts.  It 
is  quite  possible  that  waves  of  disturbance  conveyed  along 
afferent  reflex  nerves  to  certain  motor  cells,  may  be  met  by  im- 
pulses conveyed  down  through  the  ordinary  channels  connecting 
these  motor  cells  with  the  higher  nerve  centres,  in  such  a  way 
that  the  one  molecular  disturbance  will  counteract  the  other. 
This  is  rendered  more  probable,  since  various  other  instances 
may  be  adduced  to  show  that  one  nervous  action  interferes 
with  the  execution  of  another  without  anyone  ever  thinking 
of  ascribing  such  interference  to  special  inhibitory  centres  or 
fibres.  If  the  toes  of  one  leg  of  a  brainless  frog  are  dipped  into 
dilute  sulphuric  acid  at  a  time  when  the  sciatic  nerve  of  the 
other  leg  is  being  powerfully  stimulated  by  a  faradic  current,  it 
will  be  found  that  either  the  reflex  withdrawal  of  the  foot  does 
not  take  place,  or  that  the  period  of  incubation  is  much  pro- 
longed. Goltz  observed  that,  in  the  case  of  the  dog,  micturition, 
set  up  as  a  reflex  act  by  sponging  the  anus,  was  at  once  stopped 
by  sharply  pinching  the  skin  of  the  leg.  From  these,  and  many 
other  similar  examples  which  might  be  adduced,  it  is  evident 

^  Setschenow.    Ueber  die  Hemmungsmechanismen  flir  der  Keflexthiitigkeit  des 
Ruckenmarks.     1863. 


40  STRUCTURE  AND   FUNCTIONS 

that  two  sensory  impulses,  arriving  at  the  same  centre  by  diffe- 
rent paths,  may  interfere  with  each  other  in  such  a  way  that 
either  the  one  counteracts  the  other,  or  the  stronger  current 
caused  by  the  major  disturbance  drafts  off  that  caused  by  the 
minor  disturbance,  so  that  the  specific  effect  of  the  latter  does 
not  take  place.  These  considerations,  therefore,  tend  to  show 
that  inhibition  is  not  a  simple  but  a  derivative  function;  and 
that,  although  it  may  be  correct  to  speak  of  an  inhibitory  action, 
this  affords  no  warrant  for  assuming  the  existence  of  distinct 
inhibitory  centres  and  fibres. 

But  if  it  is  probable  that  this  classification  of  afferent  nerve 
fibres  errs  on  the  side  of  redundancy,  it  is  still  more  probable 
that  it  errs  on  the  side  of  deficiency.  The  reflex  afferent  fibres 
lead  to  the  peripheral  ganglia  and  spinal  cord,  while  the  sensory 
conducting  paths,  whether  consisting  of  continuous  fibres  or 
relays  of  fibres  and  cells,  have  their  terminus  in  the  cortex  of 
the  brain.  But  a  large  number  of  the  afferent  conducting  paths 
terminate  in  the  basal  ganglia,  and  more  especially  the  optic 
thalamus.  The  same  set  of  fibres  may,  however,  under  one  set  of 
circumstances  conduct  impulses  to  the  cord,  and  under  another 
to  the  optic  thalamus,  so  that  there  may  be  no  necessity  to 
assume  the  existence  of  distinct  fibres  for  conduction  to  the 
latter  ganglion.  This  remark  will  not,  however,  apply  in  the 
case  of  the  cerebellum.  Conducting  paths  must  exist  which 
convey  impulses  from  the  periphery  to  the  cerebellum  as  well 
as  to  the  cerebrum ;  hence  we  must  assume  the  existence  of 
cerebello-afferent  as  well  as  cerebro-afferent  fibres,  or  rather 
conducting  paths,  inasmuch  as  we  do  not  know  whether  these 
channels  consist  of  continuous  fibres  or  of  relays  of  fibres  inter- 
rupted by  cells. 

(ii.)  Efferent  Fibres  are  subdivided  into — (1)  Motor,  (2)  Secre- 
tory, and  (3)  Trophic  Fibres. 

(1)  Motor  Fibres. — Motor  Fibres  are  of  various  kinds.  Some 
of  these  fibres  constitute  the  efferent  branch  of  the  reflex  arc ; 
others  by  their  excitation  restrain  action,  and  hence  are  efferent 
inhibitory  fibres.  It  is  probable,  however,  that  these  fibres 
really  belong  to  the  intercentral  variety,  and  are  not  true  efferent 
fibres.  Other  fibres  are  connected  with  an  automatic  centre, 
from  which  they  convey  impulses  to  the  periphery ;  hence  they 


OF   THE   NERVOUS   SYSTEM.  41 

may  be  called  automatic  fibres.  But  i^ome  of  the  impulses 
which  are  conveyed  by  efferent  fibres  are  derived  from  still 
higher  centres,  although  it  is  doubtful  how  far  we  are  justified 
in  assuming  the  existence  of  distinct  efferent  fibres  for  each  of 
these  separate  functions.  It  is  possible,  for  instance,  that  the 
efferent  limb  of  a  reflex  arc  may  convey  voluntary  as  well  as 
reflex  impulses.  Leaving  this  question  undecided,  we  may  safely 
say  that  some  efferent  impulses  issue  from  the  basal  ganglia,  and 
the  resulting  action  may  then  from  its  complexity  be  called  com- 
pound reflex.  Other  actions  are  guided  from  the  cortex  of  the 
brain,  and  those  alone  have  a  right  to  be  called  conscious  actions. 
These  motor  actions  are  of  two  kinds.  One  kind  is  in  relation 
with  the  desires  and  appetites,  and  the  other  in  relation  with  the 
will.  What  may  be  called  the  emotional  actions  originate  in  the 
cortex  and  pass  out  through  the  basal  ganglia  and  spinal  cord ; 
while  the  voluntary  actions  originate  in  circumscribed  areas  of 
the  cortex,  called  psycho -motor  centres,  and  pass  each  through 
fibres  which  connect  the  cortex  with  the  spinal  cord  without 
being  interrupted  by  the  basal  ganglia. 

But  this  enumeration  does  not  exhaust  the  different  kinds  of 
motor  fibres,  or  rather  the  functions  of  those  fibres.  There  can 
be  no  doubt  that  a  large  number  of  the  movements  of  the  body 
are  guided  through  the  cerebellum ;  hence  it  must  be  assumed 
that  there  are  cerebello-efferent  as  well  as  cerebro -efferent  fibres. 

(2  and  8)  The  consideration  of  the  secretory  and  trophic  fibres 
may  be  deferred  for  the  present. 

(iii.)  The  Intercentral  Fibres  may  be  subdivided  into  (1) 
Commissural  fibres,  or  those  which  unite  ganglionic  centres  of 
the  same  order;  (2)  Centripetal  fibres,  or  those  which  convey 
impulses  from  a  lower  to  a  higher  centre ;  (3)  Centrifugal  fibres, 
or  those  which  convey  impulses  from  a  higher  to  a  lower  centre. 
The  words  "  centripetal "  and  "  centrifugal "  are  generally  used 
as  synonymous  with  "  afferent  "  and  "  efferent."  Mr.  Herbert 
Spencer  was  the  first  to  use  "  centripetal "  in  the  sense  given  to 
it  here,  and  it  will  conduce  to  clearness  if  a  corresponding 
meaning  be  given  to  "centrifugal."  It  must  be  remembered 
that  in  practice  it  is  not  possible  to  draw  any  sharp  line  of  dis- 
tinction between  the  fibres  which  connect  the  periphery  with  the 
centres  and  those  which  connect  the  centres  with  one  another; 


42  STRUCTURE  AND  FUNCTIONS 

hence  it  becomes  impossible  to  apply  the  terms  centripetal  and 
centrifugal  always  in  the  way  in  which  they  are  here  defined. 

§  19.  Construction  of  a  Nervous  System. — Let  us  now  con- 
sider the  relations  which  the  nervous  centres  bear  to  one 
another,  and  to  the  organism  at  large ;  or,  in  other  words,  the 
manner  in  which  the  nervous  tissues  and  mechanisms  are  put 
together  to  form  a  nervous  system.  We  have  already  seen  that 
unlike  parts  have  unlike  functions,  and  for  every  distinct  part  of 
the  organism  we  may  expect  to  find  a  distinct  function,  presided 
over  by  a  distinct  nerve  centre.  On  the  other  hand,  when  the 
parts  have  become  structurally  fused,  the  functions  also  have 
become  fused,  and  we  may  expect  to  meet  with  a  similar  fusion 
of  the  nerve  centres.  In  the  development  of  an  organism  the 
first  structural  contrast  arises  between  the  outer  and  inner  sur- 
faces, represented  by  the  epiblast  and  hypoblast  of  the  germ- 
vesicle.  The  most  fundamental  structural  and  functional 
differences  will  therefore  be  found  to  exist  between  the  outer 
system  of  organs  which  react  on  environing  agencies,  and  the 
inner  system  of  organs  which  carry  on  sustentation  ;  and  we  may 
expect  to  find  the  most  fundamental  structural  and  functional 
differences  between  the  nerve  centres  which  preside  over  these 
two  systems.  The  usual  classification  of  the  nervous  system 
into  cerebro-spinal  and  sympathetic  acknowledges  this  dis- 
tinction, since  the  first  presides  over  the  actions  of  the  external, 
and  the  second  over  those  of  the  internal  organs. 

But  a  third  layer,  called  from  its  position  the  mesoblast,  is 
formed  between  the  epiblast  and  hypoblast,  and  this  layer  gives 
origin  to  all  the  parts  of  the  body  consisting  of  connective  tissue, 
muscles,  vessels,  and  nerves.  The  parts  derived  from  this  layer 
serve  to  connect  the  external  and  internal  organs ;  and,  in  so  far 
as  the  intermediate  tissues  subserve  the  functions  of  the  external 
organs,  their  functions  are  regulated  by  the  cerebro-spinal  centres  ; 
and  when  they  subserve  the  functions  of  the  internal  organs, 
their  functions  are  regulated  by  the  sympathetic  :  while,  in  so 
far  as  their  function  is  intermediate  between  the  external  and 
internal  organs,  but  partially  independent  of  them,  they  have  an 
intermediate  and  partially  independent  nervous  system,  termed 
the  vaso-motor. 


OF   THE   NERVOUS   SYSTEM.  43 

The  next  structural  peculiarity  of  the  organism  which  we 
shall  notice  introduces  us  to  likeness,  instead  of  unlikeness,  in 
the  arrangement  of  parts,  accompanied  by  a  similarity  in  the 
distribution  of  the  nervous  centres.  A  plane,  passing  longi- 
tudinally through  a  man,  and  from  front  to  back,  would  divide 
the  body  into  two  bilaterally  symmetrical  divisions.  And  what 
is  true  of  the  body,  as  a  whole,  is  to  the  same  extent  true  of 
the  nervous  system,  since  the  same  plane  would  also  divide  it 
into  two  bilaterally  symmetrical  parts.  Now,  it  may  be  laid 
down  as  a  general  law,  that  when  the  actions  of  any  part  of  an 
organism  and  its  relations  with  other  parts  are  few  and  uniform, 
there  will  be  a  corresponding  simplicity  and  uniformity  about 
its  nervous  connections  ;  and  that,  on  the  other  hand,  when  the 
actions  to  be  performed  by  a  part  and  its  relations  with  other 
organs  are  very  numerous  and  complex,  multiformity  and  com- 
plexity will  characterise  its  nervous  connections.  The  bilaterally 
symmetrical  viscera  can  act  with  a  large  amount  of  independence 
of  one  another.  The  kidneys,  for  instance,  act  simultaneously, 
because  the  blood  conveys  to  them,  at  the  same  time,  the  agent 
which  excites  their  functional  activity,  but  the  action  of  the  one 
is  in  large  measure  independent  of  that  of  the  other.  It  is 
different,  however,  with  the  external  organs  taken  as  a  whole. 
The  two  sides  of  the  body  must  move  together,  even  when 
the  incitement  to  action  comes  from  one  side  only,  and  the 
actions  of  the  limbs  in  performing  a  definite  function,  such  as 
locomotion,  must  be  duly  co-ordinated.  These  differences  of 
functional  interdependence  between  the  internal  and  external 
bilaterally  symmetrical  organs  amongst  themselves  are  repre- 
sented by  corresponding  differences  of  structural  connections 
between  the  two  sides  of  their  respective  nervous  systems.  The 
two  gangliated  cords  situated  on  each  side  of  the  vertebral 
column,  and  which  represent  the  sympathetic  system,  are  con- 
nected transversely,  only  by  a  plexus  of  fibres  and  small  ganglia; 
while  the  two  sides  of  the  cerebro-spinal  system  are  fused 
practically  into  one  bilobed  ganglion.  In  the  spinal  cord  the 
ganglionic  substance  of  each  lateral  half  is  connected  not  merely 
by  commissural  fibres,  but  by  a  strand  of  grey  matter,  which 
undoubtedly  permits  much  more  numerous  and  complex  connec- 
tions to  be  formed  between  the  two  sides  of  the  spinal  cord  than 


44  STRUCTURE  AND  FUNCTIONS 

can  take  place  between  the  symmetrically  placed  ganglia  of  the 
sympathetic. 

The  next  structural  peculiarity  we  notice  is,  that  the  body  is 
made  up  of  a  number  of  segments  placed  end  on  end,  and  there 
is  a  corresponding  distribution  of  the  nervous  centres.  That 
this  is  the  case  with  the  greater  part  of  the  sympathetic  is 
readily  recognised.  Each  segment  of  the  body  is  represented  by 
a  vertebra  and  its  appendages ;  and  each  vertebra  has  a  gang- 
lion lying  on  each  side,  or  two  in  front  of  its  body,  one  for  each 
lateral  half  There  are  twenty-four  true  vertebrae,  but  there  are 
not  twenty-four  pairs  of  sympathetic  ganglia  corresponding  to 
these;  because  the  three  upper  cervical  on  each  side  have 
become  fused  into  one,  while  the  two  middle  and  the  two  lower 
cervical  have  respectively  become  fused  into  one.  The  sacrum 
consists  of  five  vertebrae,  which  have  become  partially  fused  into 
one  piece  ;  and  there  are  usually  five  pairs  of  ganglia  corre- 
sponding to  them,  but  their  number  is  liable  to  variation  ;  while 
the  coccyx,  although  consisting  at  an  early  age  of  four  pieces,  is 
practically  fused  into  one  bone,  and  in  front  of  it  there  is  one, 
or  at  most  two,  ganglia.  The  cranial  bones,  according  to  some 
anatomists,  represent  four  vertebrae,  which  have  become  variously 
modified  and  fused  in  the  course  of  development ;  but  the  sym- 
pathetic ganglia  corresponding  to  these  cannot  be  separately 
traced.  It  is  probable  that  they  have  become  fused  partly  with 
the  large  upper  cervical  ganglion,  and  partly  with  the  medulla, 
in  order  that  the  whole  system  may  be  brought  into  relation 
with  the  higher  centres  of  the  cerebro-spinal  system. 

But  the  internal  organs  in  the  different  segments  of  the  body 
are  neither  structurally  nor  functionally  separate,  and  we  may 
therefore  expect  that  the  ganglia  in  each  will  be  connected  with 
those  of  the  segment  above  and  below  it ;  so  that  all  of  them 
will  form  a  chain  of  ganglia,  longitudinally  as  well  as  trans- 
versely connected. 

But  the  functions  of  the  internal  organs  are  relatively  simple. 
In  the  digestive  organs,  for  instance,  the  same  series  of  processes 
have  to  be  gone  through  after  every  meal,  varying  only  with  the 
quantity  and  quality  of  the  food.  And  this  simplicity  of  func- 
tional interdependence  is  represented  by  correspondingly  simple 
interganglionic  connections.     The  main  connection  between  the 


OF   THE   NERVOUS   SYSTEM.  45 

ganglia  is  represented  by  a  cord  formed  of  a  bundle  of  fibres 
passing  down  on  each  side  of  the  vertebral  column,  and  uniting 
the  homologous  ganglia  with  one  another ;  and  when  the  con- 
nection requires  to  be  closer,  as  when  a  large  organ  occupies 
several  segments  of  the  body,  it  is  effected  by  the  plexus  already 
mentioned. 

§  20.  Fusion  of  Nerve  Centres. — The  relations  between  the 
different  segments  of  the  trunk  and  the  different  parts  of  the 
cerebro-spinal  system  are  not  easily  made  out  in  man.  In  the 
articulata,  on  the  other  hand,  these  relations  are  readily  de- 
tected, since  a  bilobed  nerve  centre  is  found  in  each  segment  of 
the  body,  forming  a  chain  of  ganglia  connected  longitudinally 
by  a  double  cord.  In  these  creatures,  however,  even  the  actions 
of  the  organs  of  external  relation  of  each  segment  possess  a  con- 
siderable amount  of  independence  of  the  actions  of  the  external 
organs  of  other  segments.  In  the  higher  animals  the  general 
actions  of  the  external  organs  are  closely  dependent  upon  one 
another.  The  body  must  move  as  a  whole ;  and,  although  the 
vetebral  column  maintains  its  segmented  character,  yet  during 
locomotion  it  is  kept  rigid  by  muscles,  especially  in  man,  so  as 
to  be  practically  one  piece.  And  corresponding  to  this  fusion 
of  the  functions  of  the  external  organs  there  is  a  correlative 
fusion  of  their  nerve  centres.  The  nerve  centres  of  each  seg- 
ment are  united  with  those  above  and  below  them,  not  simply 
by  bundles  of  fibres,  but  by  ganglionic  substance.  In  the  human 
cord,  for  instance,  the  grey  matter  of  each  lateral  half  is  con- 
tinuous from  the  lower  end  up,  not  merely  to  the  medulla,  but 
"through  the  grey  matter  of  the  floor  of  the  fourth  ventricle,  and 
that  surrounding  the  aqueduct  of  Sylvius  to  the  grey  matter 
lining  the  third  ventricle.  By  this  means  the  ganglia  of  the 
segments  have  become  so  fused  longitudinally  and  laterally,  that 
the  grey  matter  of  the  cord  fortns  a  continuous  tube  extending 
from  the  conus  medullaris  to  the  tuber  cinereum.  One  conse- 
quence of  this  fusion  of  homologous  ganglia  is,  that  the  parts  of 
the  cord  which  correspond  to  the  different  segments  of  the  body 
have  undergone  considerable  displacement.  The  cord  usually 
ends  at  the  lower  border  of  the  body  of  the  first  lumbar  vertebra, 
but  the  nerves  which  descend  to  pass  out  through  the  remaining 


46  STRUCTUEE   AND  FUNCTIONS 

lumbar  intervertebral  foramina,  and  through  the  sacral  and 
sacro-coccygeal  foramina,  show  that  the  lower  part  of  the  cord 
presides  over  the  functions  of  the  lower  segments  of  the  body, 
although  it  has  by  the  approximation  and  fusion  of  the  homo- 
logous centres  suffered  considerable  longitudinal  displacement. 

We  have  just  seen  that,  when  the  actions  of  a  part  are  nume- 
rous and  complex,  multiformity  and  complexity  will  characterise 
its  nervous  connections ;  and  we  must  now  notice  that  along 
with  multiformity  and  complexity  of  nervous  connections  there 
must  go  increasing  massiveness  of  nerve  centres.  The  large  size 
of  the  cerebro-spinal  nervous  system  which  co-ordinates  the 
numerous  and  complex  actions  of  the  organs  of  external  relation, 
in  comparison  with  the  size  of  the  sympathetic  system  which 
co-ordinates  the  simple  and  uniform  actions  of  the  organs  of 
internal  relation,  may  be  mentioned  as  an  illustration  of  this  law. 

Other  examples  of  the  law  are  met  with  on  comparing  different 
parts  of  these  systems  with  one  another ;  such,  for  instance,  as 
the  cervical  and  lumbar  enlargements  of  the  cord,  where  the 
complicated  movements  of  the  limbs  are  primarily  co-ordinated, 
in  comparison  with  the  remaining  portions  of  it,  where  the 
simpler  actions  of  the  muscles  of  the  trunk  are  co-ordinated. 
But  the  most  striking  contrast  in  size  exists  between  the  cephalic 
and  vertebral  portions  of  the  cerebro-spinal  system — a  contrast 
so  remarkable  that  it  deserves  special  examination. 

One  reason  of  the  large  size  of  the  cephalic  portion  is  that  the 
impressions  conveyed  from  the  surface  by  the  nerves  of  special 
sense  are  first  co-ordinated  by  it ;  and  since  these  impressions  are 
much  more  numerous  and  complicated  than  those  conducted  by 
the  cutaneous  nerves,  larger  nerve  centres  are  required  for  their 
co-ordination. 

As  I  sit  in  my  study,  I  receive  tactual  impressions  from  the 
chair  on  which  I  sit,  and  from  various  other  objects  which 
surround  me ;  but  on  looking  ottt  of  my  window  the  impressions 
received  by  my  eyes  are  almost  infinitely  numerous  and  com- 
plex. I  see  what  I  judge  to  be  green  fields,  houses,  horses, 
cattle,  men,  and  women,  and  on  looking  up  to  the  sky  I  am 
profoundly  affected  by  an  object  which  I  know  by  indirect 
reasoning  to  be  millions  of  miles  from  me.  The  centre,  therefore, 
which  co-ordinates  the  numerous  and  heterogeneous  impressions 


OF  THE  NERVOUS  SYSTEM.  47 

conveyed  by  the  optic  nerves  must  be  much  larger  than  those 
which  co-ordinate  the  comparatively  few  and  uniform  impressions 
conveyed  by  the  cutaneous  nerves.  As  a  proof  of  this  may  be 
cited  the  fact  that,  in  the  lower  animals,  the  first  cephalic  enlarge- 
ment, termed  the  optic  lobes,  takes  place  in  connection  with  the 
central  end  of  the  optic  nerves.  The  impressions  conveyed  by 
the  other  nerves  of  special  sense  are  less  numerous,  and,  with 
the  exception  of  the  auditory  nerves,  much  less  numerous  than 
those  conveyed  by  the  optic  nerves ;  but  they  are  more  nume- 
rous and  complex  than  those  conveyed  by  the  cutaneous  nerves, 
and,  other  things  being  equal,  require  larger  centres  for  their 
co-ordination. 

So  far  we  have  only  spoken  of  single  centres  corresponding  to 
the  different  segments  of  the  body,  and  of  the  fusion  of  these 
centres  into  bilobed  ganglia  and  continuous  masses.  But  in  the 
course  of  development  superior  centres  arise,  which  co-ordinate 
and  control  the  inferior  centres ;  but  before  a  superior  can  con- 
trol inferior  centres  there  must  be  a  nervous  connection  between 
them;  hence  the  superior  centre,  which  has  to  co-ordinate  the 
actions  of  a  large  number  of  inferior  centres,  must  be  more 
massive  than  each  of  the  latter.  In  the  higher  animals  not  only 
do  we  meet  with  compound  co-ordinating  centres,  but  we  also 
meet  with  doubly-compound,  and  probably  even  trebly-compound 
co-ordinating  centres,  each  of  them  increasing  in  massiveness 
according  to  its  position  in  the  ascending  scale  of  complexity. 
Now,  in  the  lower  animals  the  cephalic  extremity  has  to  move 
foremost  and  to  encounter  dangers,  and  it  therefore  becomes  the 
end  to  which  the  actions  of  the  rest  of  the  organism  must  be 
subordinated;  hence  the  compound  co-ordinating  centres  must 
necessarily  be  aggregated  in  this  extremity.  If,  then,  it  is 
considered  that  not  only  the  simple  centres,  which  primarily 
co-ordinate  the  impressions  conveyed  by  the  nerves  of  special 
sense,  but  also  the  compound  and  doubly-compound  centres, 
which  co-ordinate  all  the  impressions  of  external  agencies  on  the 
organism  with  one  another,  and  determine  the  reactions  of  the 
organism  as  a  whole  to  external  agencies,  are  lodged  in  the 
cephalic  extremity  of  animals,  it  will  be  at  once  apparent  why 
the  cephalic  is  so  much  more  massive  than  the  vertebral  portion 
of  the  cerebro-spinal  nervous  system. 


48  STRUCTURE   AND   FUNCTIONS 

g  21. — EncepJialo- Spinal  System. — These,  theia,  are  the  main 
laws  which  regulate  the  construction  of  a  nervous  system,  and 
before  proceeding  further  it  will  be  useful  to  obtain  a  general 
view  of  the  leading  features  of  the  structure  of  the  encephalo- 
spinal  S3^stem.  The  ganglion  cells  of  this  system  are  collected 
into  five  principal  masses  of  grey  matter  : — (1)  The  cortex  of  the 
cerebral  hemispheres  ;  (2)  the  basal  ganglia;  (3)  the  cortex  of  the 
cerebellum ;  (4)  the  grey  matter  of  the  corpora  dentata  of  the 
cerebellum,  with  which  may  be  associated  the  olivary  bodies  of  the 
medulla  and  the  red  nuclei  of  the  tegmenta;  and  (5)  the  tubular 
mass  of  grey  matter  which  extends  from  the  tuber  cinereum  to 
the  conus  medullaris  of  the  spinal  cord.  Seeing  that  the  central 
grey  tube  of  the  spinal  cord  enters  into  connection  with  the 
grey  substance  of  both  the  cerebrum  and  cerebellum,  the  en- 
cephalo-spinal  system  may  be  subdivided  into  the  cerebro- spinal 
and  cerebello-spinal  systems ;  and  even  if  the  latter  of  these  two 
systems  is  to  some  extent  subordinate  to  the  former,  it  is  largely 
independent  of  it,  and  consequently  the  two  may  be  regarded  as 
performing  co-ordinate  functions. 

§  22.  Cerehro- Spinal  System. — Let  us  return,  in  the  first 
place,  to  the  general  structure  of  the  cerebro-spinal  system. 
The  accompanying  diagram  from  Landois'  "  Physiologie "  is  a 
schematic  representation  of  the  cerebro-spinal  system.  The 
cortex  of  the  brain  is  represented  by  (C  C)  ;  the  basal  ganglia 
are  represented  by  (C  s),  the  caudate  nucleus  of  the  corpus 
striatum  ;  (N  l)  the  lenticular  nucleus  ;  (T  o),  the  optic  tha- 
lamus ;  and  V,  the  corpora  quadrigemina.  The  tegmentum  and 
crusta  are  represented  respectively  by  H  and  p.  The  crura  are 
represented  by  P;  while  R  represents  a  section  of  the  spinal 
cord,  and  h  W  and  v  W  the  posterior  and  anterior  roots  of  the 
peripheral  nerves  respectively.  The  central  grey  tube  extends 
from  P  to  R  The  fibres  (c  c)  and  (a  a)  represent  intercentral 
fibres,  the  former  connecting  points  in  one  hemisphere  with 
analogous  points  in  the  other  ;  while  the  latter  connect  different 
points  of  the  same  hemisphere. 

If  with  Meynert^  we  take  our  point  of  departure  from  the 

1  Meynert  (Theodor).  "  The  Brain  of  Mammals."  Strieker's  Manual  of  Human 
and  Comparative  Histology.  Translated  by  Henry  Power,  M.B.,  London.  Syd. 
Soc,  Lond.,  1872.     p.  372  et  seq. 


OF   THE   NERVOUS   SYSTEM. 


49 


Fig.  2. 


Fig.  2.  Schema  of  the  Cerebrospinal  System  (from  Landois'  "Physiologie"). — 
C,  C,  Cortex  "of  the  Brain  ;  C  s.  Corpus  Striatum  ;  N  I,  Lenticular  Nucleus  ; 
T  o,  Optic  Thalamus ;  V,  Corpora  Quadrigemina ;  P,  Crura  Cerebri ;  H, 
Tegmentum ;  p,  Crusta  ;  1  1,  Kadiate  Fibres  of  the  Corpus  Striatum ;  2  2, 
those  of  the  Lenticular  Nucleus  ;  3  3,  those  of  the  Optic  Thalamus  ;  4  4,  those 
of  the  Corpora  Quadrigemina.  5  5,  the  Pyramidal  Tract.  6  6,  Fibres  con- 
necting the  Corpora  Quadrigemina  and  Tegmentum  ;  m,  their  further  course, 
8  8,  Fibres  connecting  the  Corpus  Striatum  and  Lenticular  Nucleus  with  the 
Crusta ;  M,  their  further  course.  S,  S,  course  of  the  Sensory  Fibres.  R, 
Transverse  Section  of  the  Spinal  Cord ;  v  W,  Anterior,  and  h  W,  Posterior 
Roots  of  the  Nerves.  a,  a,  associating  Fibres  ;  c,  c,  Commissural  Fibres. 
II,  Transverse  Section  through  the  Crura  Cerebri  of  Man  on  a  level  with  the 
posterior  pair  of  the  Corpora  Quadrigemina  (after  Meynert) ;  p,  Crusta ;  S, 
Locus  Niger  ;  v,  the  posterior  pair  of  the  Corpora  Quadrigemina  with  the 
Aqueduct  of  Sylvius.  Similar  sections  from  the  Crura  of — III,  Dog;  IV, 
Monkey  ;  V,  Guinea  Pig. 


VOL.  I. 


E 


50  STEUCTURE  AKD   FUNCTIONS 

cortex  of  the  cerebrum,  and  if,  like  him,  we  regard  as  the  object 
of  all  nervous  action  the  projection  of  the  image  of  the  various 
forms  of  sensory  impressions  derived  from  the  external  world 
upon  the  cortex,  the  fibres  which  radiate  from  the  latter  to  the 
basal  ganglia,  those  which  unite  the  basal  ganglia  with  the  cord, 
and  the  peripheral  nerves,  may  together  be  called  the  "projection 
system." 

(1)  Inner  System  of  Projection. — The  inner  system  of  pro- 
jection, or  the  corona  radiata,  is  represented  in  Fig.  2  by  fibres 
(1  1)  connecting  the  cortex  of  the  brain  and  the  caudate  nucleus  ; 
and  by  fibres  (2  2),  (3  8),  and  (4  4)  connecting  the  cortex  with 
the  lenticular  nucleus,  optic  thalamus,  and  corpora  quadrigemina 
respectively.  Of  these  the  fibres  which  connect  the  corpora 
quadrigemina  and  optic  thalamus  with  the  cortex  convey  impulses 
towards  the  latter,  and  are  therefore  centripetal;  while  those 
which  connect  the  cortex  and  the  caudate  and  lenticular  nuclei 
convey  impulses  from  the  cortex  outwards,  and  are  therefore 
centrifugal. 

(2)  Middle  System  of  Projection.  —  The  second  system  of 
projection  connects  the  basal  ganglia  with  the  central  grey  tube. 
It  will  be  observed  that  the  fibres  (7)  and  (6  6),  which  connect 
the  thalamus  and  corpora  quadrigemina  respectively  with  the 
central  grey  tube,  join  the  latter  through  the  tegmentum  (H) ; 
while  (8  8),  the  fibres  which  connect  the  caudate  and  lenticular 
nuclei  with  the  central  grey  tube,  join  the  latter  through  the 
crusta.  The  fibres  which  pass  through  the  tegmentum  (6  6)  and 
(7)  are  afi'erent,  and  are  continued  through  the  cord  on  the  same 
side  (m),  but  finally  cross  to  the  opposite  side,  near  the  level  at 
which  the  peripheral  nerve  joins  the  central  grey  tube ;  while 
the  fibres  (8  8),  which  pass  through  the  crusta,  are  efferent,  and 
are  represented  in  the  figure  as  crossing  over  to  the  opposite 
side  at  the  lower  part  of  the  medulla,  and  as  being  then  con- 
tinued onwards  (M)  in  the  opposite  half  of  the  cord.  It  is, 
however,  very  doubtful  whether  these  fibres  do  cross  in  the 
lower  part  of  the  medulla.  The  fibres  which  cross  in  the 
medulla  appear  all  to  belong  to  the  system  of  fibres  which  con- 
nect the  cortex  of  the  brain  directly  with  the  central  grey 
tube,  and  which  will  be  immediately  described  under  the  name 
of  the  "  pyramidal  tract." 


OF  THE  NERVOUS   SYSTEM.  51 

(3)  Outer  System  of  Projection. — The  third  system  of 
projection  is  constituted  by  A  W  and  v  W,  the  posterior  and 
anterior  roots  of  the  peripheral  nerves,  the  former  being  afferent 
and  the  latter  efferent. 

(4)  Optic  Radiations  of  Gratiolet — It  will  be  seen,  how- 
ever, that  the  fibres  which  connect  the  cortex  of  the  brain  and 
the  central  grey  tube  are  not  yet  exhausted.  It  will  be  ob- 
served that  (S)  and  (5  5)  represent  fibres  which  connect  these 
centres  without  being  interrupted  by  the  basal  ganglia.  The 
fibres  represented  by  (S)  issue  from  the  convolutions  of  the 
occipital  lobe,  and  converge  towards  the  posterior  portion  of 
the  internal  capsule — the  white  substance  which  lies  between 
the  thalamus  and  caudate  nucleus  on  the  one  hand,  and  the 
lenticular  nucleus  on  the  other — where  they  constitute  one 
bundle  of  fibres  which  has  been  called  the  optic  radiations  of 
Gratiolet,^  after  the  anatomist  who  first  described  it.  This 
bundle  is  frequently  destroyed  by  disease  of  the  internal  capsule, 

•  and  then  loss  of  feeling  of  the  opposite  side  of  the  body  results. 
There  are  no  grounds  for  believicg  that  all  these  fibres  cross  in 
the  medulla,  as  they  are  represented  as  doing  in  the  figure.  It 
is  more  probable  that  they  cross  to  the  opposite  side,  on  a  level 
with  the  point  at  which  the  peripheral  nerve  with  which  they 
are  connected  joins  the  cord. 

(5)  Pyramiclal  Tract. — The  fibres  represented  by  (5  5  M) 
issue  from  the  convolutions  of  the  middle  lobe  of  the  brain,  and 
converge,  on  descending,  until  they  form  one  bundle  which 
occupies  about  the  middle  third  of  the  internal  capsule.  These 
fibres  proceed  downwards  without  being  interrupted  by  the  basal 
ganglia,  and  occupy  the  middle  third  of  the  crusta  {Fig.  5,  p  p'), 
where  they  still  form  one  bundle.  In  the  pons  these  fibres  are 
split  up  into  several  bundles  by  the  transverse  fibres  of  the  middle 
peduncles  of  the  cerebellum ;  but  they  come  together  again 
to  form  one  bundle  in  the  medulla,  where  they  constitute  the 
anterior  pyramid.  At  the  lower  part  of  the  medulla  the  greater 
number  of  these  fibres  cross  over  to  the  opposite  side,  and  are 
also  directed  backwards  so  as  to  form  the  posterior  part  of  the 
lateral  column  of  the  cord  {Fig.  4,  p  p'),  where  some  of  these 

1  Gratiolet  (M.  Pierre).  Anatomie  Comparee  du  Systeme  Nerveux.  Paris, 
1839-57.    p.  179. 


52  STRUCTURE  AND  FUNCTIONS 

fibres  are  continued  onwards  to  the  lower  end  of  the  central  grey 
tube.  A  small  number  of  these  fibres  do  not  cross  in  the  medulla, 
but  are  continued  downwards  in  the  cord  in  the  anterior  column 
close  to  the  median  fissure,  constituting  the  column  of  Tiirck 
(Fig.  4,  T).  Inasmuch  as  these  fibres  form  the  anterior  pyramids 
of  the  medulla,  they  are  called  the  pyramidal  tracts.  A  trans- 
verse section  of  the  crura  cerebri  of  man  is  represented  in  Fig. 
(2,  II),  on  a  level  with  the  posterior  pair  of  the  corpora  quadri- 
gemina  (testes),  p  represents  the  crusta,  s  the  substantia  nigra, 
V  the  corpora  quadrigemina  and  the  aqueduct  of  Sylvius,  while 
the  tegmentum  lies  between  that  and  the  locus  niger.  In  Fig. 
(2,  III,  IV,  Y)  similar  sections  are  represented  respectively  of  the 
crura  of  the  dog,  ape,  and  guinea-pig.  It  has  been  observed  by 
Mevnert  that  the  relative  sizes  of  transverse  sections  of  the  crura 
in  different  animals  bear  a  close  relationship  to  the  relative  sizes 
of  their  brains.  It  would  not  be  safe  to  draw  any  general  con- 
clusion from  such  a  comparison  as  is  here  made  with  sections  of 
the  crura  in  different  animals ;  but  everyone  must  be  struck  with ' 
the  enormous  relative  bulk  of  the  crusta  in  the  crura  of  man — 
a  fact  which  is  of  very  great  significance  when  it  is  considered 
that  the  pyramidal  tract  passes  through  it,  the  fibres  of  this 
tract  being  almost  certainly  those  which  convey  the  voluntary 
impulses  from  the  cortex  to  the  central  grey  tube. 

§  23.  The  Cerebellospinal  System  is  much  less  surely  known 
than  tbecerebro-spinal,  and  the  following  schema  must  be  taken 
to  represent,  along  with  a  few  certainties,  a  considerable  number 
of  conjectures. 

The  cerebellum  consists  of  a  body  and  three  pairs  of  crura, 
by  means  of  which  it  is  connected  with  the  rest  of  the  en- 
cephalo-spinal  axis.  The  grey  substance  of  the  cerebellum  is 
found  in  the  cortex  (Fig.  3,  C  C)  and  in  the  dentate  nuclei 
{Fig.  3,  D  D),  and  in  the  roof  nuclei  of  Stilling,  the  latter  of 
which  we  may  neglect  at  present,  both  because  they  are  small 
and  because  very  little  is  known  with  respect  to  their  connec- 
tions. But  the  olivary  bodies  {Fig.  3,  0)  of  the  medulla  and 
the  red  nucleus  {Fig.  3,  R)  of  the  tegmentum  are  similar  in 
structure  to  the  dentate  nuclei,  and  they  are  also  closely  con- 
nected respectively  with  the  inferior  and  superior  peduncles  of 


OF  THE  NERVOUS  SYSTEM. 
Fig.  3. 


53 


Fig.  3.  Schema  of  the  Cerebdlo-Spinal  System. — C,  C,  Cortex  of  the  Cerebellum. 
D,  D,  Corpora  Dentata.  O,  O,  Olivary  Bodies.  K,  Red  Nucleus  of  Tegmen- 
tum. P,  Grey  matter  interposed  between  transverse  Fibres  of  the  Pons.  CR, 
Crura  Cerebri.  C,  Crusta.  S,  Substantia  Nigra.  T,  Tegmentum.  A,  Aque- 
duct of  Sylvius.  1,  Fibres  which  connect  the  cortex  of  the  Cerebrum  and  that 
of  the  Cerebellum  on  the  opposite  side.  2,  2,  Fibres  connecting  the  Cortex  of 
Cerebellum  and  Red  Nucleus  of  the  opposite  side.  3,  3,  Fibres  connecting  the 
Corpus  Dentatum  of  the  Cerebellum  with  the  Red  Nucleus  of  the  opposite 
side.  4,  4,  Fibres  connecting  the  Cortex  of  the  Cerebellum  with  the  Corpus 
Dentatum.  5,  Fibres  connecting  the  Cortex  of  the  Cerebellum  with  Grey 
substance  interposed  between  the  transverse  Fibres  of  the  Pons  on  the  opposite 
side.  6,  Fibres  connecting  the  Corpus  Dentatum  with  the  Olivary  body  of  the 
opposite  side.  7,  Fibres  connecting  the  Cortex  of  the  Cerebellum  with  the 
Olivary  body  of  the  opposite  side.  8,  8,  Fibres  connecting  the  Red  Nucleus. 
9,  9,  those  connecting  the  interposed  Grey  substance  of  the  Pons,  and  9",  those 
connecting  the  Olivary  body  respectively  with  the  anterior  Grey  Horn  of  the 
Spinal  Cord.  M,  The  Anterior  Column  of  the  cord  through  which  the  fibres 
pass,  g.  Column  of  Gol)  terminating  in  c  w  the  Clavate  Nucleus.  10,  Arcuate 
Fibres  connecting  the  Clavate  Nucleus  with  the  Olivary  body  of  the  same  side. 
p  r.  The  Posterior  Root-Zone  terminating  in  t  n,  the  Triangular  Nucleus.  11, 
Arcuate  Fibres  connecting  Triangular  Nucleus  and  Olivary  body  of  same  side. 
dc,  dc,  Direct  Cerebellar  Fibres  ascending  in  the  lateral  column  of  the  cord  and 
connecting  the  vesicular  column  of  Clarke  with  the  Cortex  of  the  Cerebellum. 


54  STRUCTUKE  AND   FUNCTIONS 

the  cerebellum,  so  that  it  is  almost  certain  that  they  belong  to 
the  cerebellar  system.  To  these  structures  may  be  added  the 
grey  substance  interposed  between  the  fibres  of  the  middle 
peduncles  of  the  cerebellum  as  they  pass  in  front  of  and  into 
the  substance  of  the  pons,  which  is  represented  by  (P)  in  the 
figure,  and  which  may  be  called  the  anterior  grey  substance  of 
the  pons. 

(1)  Intermediate  Ganglia  of  Cerebellum. — The  dentate  nuclei 
(D  D),  the  olivary  bodies  (O  O),  the  red  nuclei  (E.),  and  the  an- 
terior grey  substance  of  the  pons  (P),  bear  the  same  intermediate 
relationship  to  the  cortex  of  the  cerebellum  and  the  spinal  cord 
that  the  basal  ganglia  bear  to  the  cortex  of  the  cerebrum  and 
the  cord ;  hence  they  may  be  briefly  termed  the  intermediate 
ganglia  of  the  cerebello-spinal  system. 

(2)  Cerebellar  Projection  System. — Following  then  the  nomen- 
clature of  Meynert,  the  fibres  which  connect  the  cortex  of  the 
cerebellum  with  the  intermediate  ganglia  may  be  called  the 
inner  system  of  projection ;  those  which  connect  the  inter- 
mediate ganglia  with  the  spinal  cord,  the  middle  system  of  pro- 
jection, and  the  peripheral  nerves,  themselves  form  the  outer 
system  of  projection  for  the  cerebellum  as  well  as  for  the 
cerebrum. 

(3)  Cerebellospinal  Conducting  Paths. — The  inner  system 
of  projection  is  formed  by  the  fibres  which  connect  the  cortex 
of  the  cerebellum  with  the  dentate  nucleus  (4  4),  those  which 
connect  the  cortex  with  the  red  nucleus  (2),  the  anterior  grey 
substance  of  the  pons  (5),  and  the  olivary  body  (7),  all  of  the 
opposite  side.  To  the  same  system  of  fibres  belong  those  (3  8) 
which  connect  the  dentate  nucleus  with  the  red  nucleus,  and 
(6)  with  the  olivary  body  of  the  opposite  side.  The  middle 
system  of  projection  is  less  known  than  the  inner  system.  But 
since  the  olivary  body,  the  anterior  grey  substance  of  the  pons, 
and  the  red  nucleus  of  the  tegmentum  are  closely  connected  with 
the  anterior  white  columns  of  the  cord  (M)  and  their  continua- 
tion through  the  medulla  oblongata,  pons,  and  crura,  it  may  be 
inferred  that  the  efferent  impulses  from  the  cerebellum  are  con- 
veyed through  these  columns  which  are  known  to  be  motor  in 
their  functions ;  hence  the  efferent  portion  of  the  middle  projec- 
tion of  the  cerebello-spinal  system  is  represented  by  9  9'  and  9" 


OF  THE  NERVOUS   SYSTEM, 


55 


which  connect  the  red  nucleus,  the  anterior  grey  substance  of 
the  pons,  and  the  olivary  body  respectively  with  the  anterior 
horns  of  the  central  grey  tube. 

(4)  Posterior  Root-Zones  and  Column  of  Goll. — The  afferent 
portion  of  the  middle  projection  system  still  requires  notice. 
Between  the  posterior  roots  (Fig.  3,  p)  of  the  spinal  nerves  and 
the  posterior  median  fissure  lies  the  posterior  white  column, 
which  is  divided  into  two  portions ;  an  inner  wedge-shaped  por- 
tion called  the  column  of  Goll  {Fig.  4,  G),  the  fibres  {Fig.  8,  g) 
of  which  ascend  to  terminate  in  a  grey  nucleus  called  the 
clavate  nucleus  {Fig.  S,  c  n)  ;  and  an  outer  portion  called 
the  posterior  root-zone  {Fig.  4,  p  r),  the  fibres  of  which 
(Fig.  3,  p  r)  also  ascend  (although  probably  in  a  succession  of 
loops  instead  of  continuously)  to  terminate  at  the  lower  end  of 
the  medulla  in  a  grey  nucleus  termed  the  triangular  nucleus 
{Fig.  3,  t  n).  From  the  clavate  and  triangular  nuclei  fibres 
{Fig.  3,  10,  11)  issue  which  end  in  the  olivary  body  of  the  same 
side;  so  that  through  the  medium  of  these  nuclei  and  the 
olivary  body,  some  at  least  of  the  fibres  of  the  posterior  column 
form  a  crossed  connection  with  the  cortex  of  the  cerebellum; 


Fig.  4. 


'7/. 


aJi 


B dc 


Tig.  4.  Cord  of  Human  Embryo  at  five  months. — ah,  ah'.  Anterior  Horns  of  grey 
substance ;  ph,  ph',  Posterior  Horns  of  grey  substance ;  ar,  ai-'.  Anterior  Root- 
Zones;  tir,  p?.  Posterior  Eoot-Zones;  P,  P',  Pyramidal  Fibres  of  lateral 
columns ;  T,  Columns  of  Tiirck ;  G,  Columns  of  Goll ;  dc,  dc'.  Direct  cerebellar 
fibres;  c,  Anterior  Commissure. 


56  STRUCTUEE  AND  FUNCTIONS 

aad  these  fibres  very  probably  constitute  the  afferent  portion  of 
the  middle  system  of  projection  of  the  cerebellum.  The  outer 
system  of  projection  is  formed  by  the  nerves,  and  all  that  need 
be  said  respecting  it  is  to  remind  the  reader  that  the  peripheral 
nerves  must  convey  afferent  and  efferent  impulses  to  and  from 
the  cerebellum,  as  well  as  to  and  from  the  cerebrum,  and  even  if 
it  be  shown  hereafter  that  the  same  fibres  execute  both  func- 
tions, yet  the  existence  of  the  former  function  should  not  be 
overlooked  and  merged  in  the  more  conspicuous  phenomena 
which  attend  the  latter  function. 

(5)  Fibres  connecting  the  Cerebellum  and  Cerebrum. — 
Two  other  conducting  paths  in  connection  with  the  cerebellum 
have  still  to  be  noticed.  One  of  them  springs  from  the  cortex 
(Fig.  3,  1,  1),  ascends  in  the  superior  peduncle,  crosses  over  to 
the  opposite  side  in  the  tegmentum,  and  ascends  through  the  in- 
ternal capsule  to  reach  the  cortex  of  the  cerebrum,  thus  forming 
a  straight  connection  between  the  two  superior  ganglionic 
centres.  It  is  also  probable  that  an  interrupted  connection 
exists  between  the  two  through  the  medium  of  the  red  nucleus 
and  the  optic  thalamus.  The  decussation  of  the  fibres  of  the 
superior  peduncles  of  the  cerebellum  is  represented  in  Fig.  5,  x, 
which  also  shows  the  position  of  the  red  nuclei  (R  R')  of  the 
tegmentum. 

(6)  Direct  Cerebellar  Fibres. — The  second  conducting  path  is 
one  which  issues  from  the  central  grey  tube  at  the  junction  of 
the  anterior  and  posterior  grey  horns,  and  the  fibres  {Fig.  8, 
d  c,  d  c)  of  which,  after  passing  outwards  to  reach  the  surface  of 
the  lateral  column  of  the  cord  (Fig.  4,  d  c),  ascend  and  pass 
through  the  restiform  bodies  to  gain  the  cortex  of  the  cerebellum. 
These  fibres  form  a  straight  connection  between  the  cortex  of  the 
cerebellum  and  the  central  grey  tube,  without  being  interrupted 
by  grey  substance,  and  they  are  consequently  called  the  direct 
cerebellar  fibres.     Their  functions  appear  to  be  afferent. 

§  24).  Functions  of  Encephalo-Spinal  System. — With  respect 
to  the  functions  of  the  encephalo-spinal  system,  all  recent 
researches  have,  in  my  opinion,  tended  to  confirm  Mr.  Herbert 
Spencer's   hypothesis,^    "that   the   cerebellum   is   an   organ   of 

1  Spencer.    The  Principles  of  Psychology,    Vol.  I.,  1870,  p.  62. 


OF  THE  NERVOUS   SYSTEM, 


57 


doubly-compound  co-ordination  in  space,  while  the  cerebrum  is 
an  organ  of  doubly-compound  co-ordination  in  time,"  This 
hypothesis,  originally  stated  in  very  general  terms,  has  been 
adopted  by  Dr,  Hughlings  Jackson,^  and  applied  by  him 
with  wonderful  fertility  of  resource  to  the  explanation  of  the 
phenomena  of  disease. 

According  to  this  theory,  the  cerebellum  regulates  the  mus- 
cular contractions  necessary  for  the  maintenance  of  all  our 
attitudes  in  space,  while  the  cerebrum  regulates  the  contractions 
necessary  to  effect  all  the  changes  of  attitude  which  are  made 
in  response  to  the  successive  impressions  occurring  in  time, 
Now,  so  long  as  a  particular  attitude  is  maintained  in  oppo- 


Zi/; 


'j»/' 


-£^ 


Fig.  5,  Crura  Cerebri.  — Transverse  Section  of  the  Crura  Cerebri  on  a  level  with 
the  anterior  pair  of  the  Corpora  Quadrigemina :  from  a  nine-months  human 
embryo.  The  dark  portions  represent  MeduUated  Fibres,  s,  Aqueduct  of 
Sylvius;  q,  q",  Anterior  pair  of  Corpora  Quadrigemina;  pf,  pf,  Fasciculi  of 
MeduUated  Fibres  proceeding  to  the  anterior  pair  of  Corpora  Quadrigemina ; 
L,  L',  Posterior  Longitudinal  Fasciculi ;  V,  V,  portions  of  these  Fasciculi 
which  join  the  posterior  commissure  of  the  third  ventricle ;  g,  g\  External 
Geniculate  Bodies ;  af,  af.  Anterior  portion  of  Fillet ;  n,  n'.  Substantia  Nigra ; 
E,  R',  Red  Nuclei ;  p,  p',  Pyramidal  Tract ;  c,  c',  Crustse ;  3,  3',  Third  pair 
of  nerves ;  x.  Decussation  in  front  of  the  Aqueduct  of  Sylvius,  which  is  part 
of  the  interlacement  of  the  Tegmentum. 


1  Hughlings  Jackson  (J.).    The  Medical  Times  and  Gazette,  Dec.  14-21,  1S67. 
Also  Ibid.    Vol.  II.,  1878,  p,  485, 


58  STRUCTURE  AND  FUNCTIONS 

sition  to  gravity  and  other  forces,  the  contractions  of  the 
various  groups  of  muscles  concerned  must  be  continuous  and 
in  equilibrium  with  one  another ;  while  each  change  of  attitude 
necessitates  the  overthrow  of  this  equilibrium,  involving  the 
preponderance  of  the  contractions  of  some  groups  of  muscles 
over  those  of  others,  so  that  change  of  attitude  involves  alter- 
nate muscular  contractions  and  relaxations.  Speaking  broadly, 
then,  the  cerebellum  regulates  continuous  or  tonic  muscular 
contractions,  while  the  cerebrum  regulates  alternate  or  clonic 
contractions.  It  will  be  seen,  therefore,  that  every  compound 
muscular  adjustment  necessitates  the  co-operation  of  both  these 
organs.  No  change  of  attitude  can  be  effected  by  the  cerebrum 
except  in  so  far  as  a  certain  attitude  was  previously  maintained 
by  the  cerebellum,  and  no  steady  movement  can  be  produced  by 
the  alternate  contractions  of  some  groups  of  muscles  except  in 
so  far  as  other  groups  of  muscles  are  maintained  in  a  state  of 
continuous  contraction ;  hence  it  may  be  inferred  that  all  the 
movements  of  the  body  are  co-ordinated  both  in  the  cerebellum 
and  cerebrum. 

But  although  the  functions  of  the  cerebellum  and  cerebrum- 
are  to  a  considerable  extent  co-ordinate,  yet  it  is  manifest  that 
the  former  must  act  in  subordination  to  the  latter.  If  animals 
only  possessed  the  power  of  maintaining  one  unvarying  attitude, 
they  would  not  require  capacities  higher  than  those  of  inanimate 
objects;  the  degree  of  development  to  which  an  animal  has 
attained  is  measured  by  its  capacity  of  effecting  multitudinous 
changes  of  attitude.  Now,  in  effecting  these  changes,  the  alter- 
nate contractions  under  the  guidance  of  the  cerebrum  must  take 
the  lead ;  and  any  change  which  is  necessarily  produced  in 
the  continuous  contractions,  although  regulated  through  the 
cerebellum,  must  be  in  strict  subordination  to  the  action  of  the 
cerebrum. 

§  25.  Functions  of  Cerehro-Spinal  System. — We  have  so  far 
spoken  of  the  functions  of  the  cerebrum  and  cerebellum  only ; 
but  it  would  be  more  correct  to  speak  of  the  functions  of  the 
cerebro-spinal  and  cerebello-spinal  systems,  inasmuch  as  neither 
of  the  higher  centres  can  act  except  through  the  medium  of  the 
spinal  cord  and  peripheral  nerves,  which  are  common  to  both 


y 


OF   THE  NERVOUS   SYSTEM.  59 

organs.  But,  however  convenient  it  may  be  from  a  structural 
point  of  view  to  follow  Meynert,  and  take  our  starting  point  from 
the  higher  centres,  yet  from  a  functional  point  of  view  it  will  be 
more  convenient  to  start  from  the  periphery.  The  order  of  the 
development  of  the  nervous  system  is  not  from  the  cortices  of 
the  cerebrum  and  cerebellum  to  the  central  grey  tube,  but  from 
the  latter  to  the  former  ;  hence  it  is  more  philosophical  to  make 
the  central  grey  tube  rather  than  the  cortices  the  starting  point 
of  our  representation.  According  to  this  view  the  central  grey 
tube,  along  with  the  peripheral  nerves,  constitutes  a  system  of 
compound  co-ordination  in  time  (reflex  action)  ;  the  basal 
ganglia  when  acting  upon  the  central  grey  tube  and  peripheral 
nerves,  form  a  system  of  compound  co-ordination  in  time  (in- 
stinctive action) ;  and  the  cortex  of  the  brain,  when  acting  on 
the  inferior  centres,  forms  a  system  of  doubly-compound  co- 
ordination in  time  (conscious  actions). 

§  26.  Functions  of  Cerehello-Spinal  System. — The  functions 
of  the  cerebello-spinal  system  may  be  similarly  represented. 
The  central  grey  tube,  along  with  the  peripheral  nerves,  forms 
a  system  of  simple  co-ordination  in  space  as  well  as  in  time 
(reflex  tonus);  the  intermediate  ganglia  of  the  cerebello-spinal 
system  acting  on  the  central  grey  tube  and  peripheral  nerves 
form  a  system  of  compound  co-ordination  in  space  (the  main- 
tenance of  unvarying  attitudes) ;  while  the  cortex  of  the  cere- 
bellum acting  on  the  inferior  centres  forms  a  system  of  doubly- 
compound  co-ordination  in  space  (the  adjustments  of  the  tonic 
contractions  of  the  muscles  rendered  necessary  by  changes  of 
attitude). 

§  27.  Co-operation  of  Cerehro-Spinal  and  Cerebello-Spinal 
Systems. — According  to  this  theory,  then,  the  multitudinous 
adjustments  of  the  body,  both  in  time  and  space,  are  regulated 
by  the  combined  action  of  the  cerebrum  and  cerebellum  acting 
through  the  spinal  cord  and  peripheral  nerves.  The  co-operation 
of  these  organs  in  the  regulation  of  motor  actions  is,  however, 
generally  of  an  antagonistic  kind.  The  cerebellum  tends  to 
maintain  an  unvarying  attitude,  while  the  cerebrum,  in  initiating 
a  change  of  attitude,  must  act  by  overthrowing  the  balance  of 


60 


STRUCTURE  AND   FUNCTIONS 


Fig.  6. 


the  muscular  contractions  which  maintain  this  attitude.  The 
overthrow  of  this  equilibrium  can  be  effected  by  the  cerebrum 
in  either  of  two  ways,  either  'positively  by  an  increase  of  nervous 
impulses  to  certain  groups  of  muscles,  or  negatively  by  arresting 
or  inhibiting  in  the  spinal  centres  the  cerebellar  influx  to  their 
antagonists.  Now  it  is  manifest  that  the  latter  method  would 
be  much  more  economical  than  the  former,  and  consequently 
there  is  every  reason  to  believe  that  the  cerebrum  does  act 
largely  by  inhibiting  the  action  of  the  cerebellum,  although  it 
is  also  certain  that  it  must  exercise  a  positive  control  over  the 

various  muscular  contractions. 
The  conjoint  action  of  the  cen- 
tral grey  tube,  the  cerebrum  and 
cerebellum,  is  represented  in  the 
accompanying  diagram  {Fig.  6) 
under  the  simplest  conditions. 
A  ganglion  cell  of  the  spinal  cord 
is  represented  by  s,  of  the  cere- 
brum by  c,  of  the  cerebellum 
by  c'.  The  afferent  conducting 
paths  from  the  periphery  to  the 
spinal  cord,  cerebrum,  and  cere- 
bellum are  represented  by  a,  a', 
a"  respectively.  The  efferent 
conducting  path  between  the 
cerebrum  and  spinal  cord  is 
represented  by  e,  between  the 
cerebellum  and  cord  by  e",  and 
between  the  cord  and  muscles 
by  e  ;  while  m  m  represent  the 
muscles    themselves,    and    the 


Fig.  6 


Schema  of  Encephalo- Spinal 
Action. — s,  Motor  ganglion  cell  of 
spinal  cord;  c,  Ganglion  cell  of  cor- 
tex of  cerebrum,  and  c',  of  cortex  of 
cerebellum ;  a,  a',  a",  Afferent  fibres 
to  the  spinal  cord,  and  to  the  cortices 
of  the  cerebrum  and  of  the  cerebellum 
respectively ;  e,  e,  Efferent  fibres 
from  the  spinal  ganglion  cell  to 
m,  m',  the  muscles ;  e'  and  e",  Fibres 
from  the  cerebral  and  cerebellar  cells 
respectively  to  the  spinal  ganglion 
cell ;  i,  Intercentral  Fibre  connect- 
ing the  cerebral  and  cerebellar  cells. 
The  arrows  indicate  the  direction  of 
the  conduction. 


arrows  indicate  the  direction  of 
the  currents.  Now,  when  an 
impression  is  made  upon  a,  it 
is  conveyed  to  s,  and  reflected 
through  e  e  to  m  m,  this  con- 
stituting a  simple  reflex  action. 
When  an  impression  is  made 
upon  a",  the  impulse  is  conveyed 


z' 


OF   THE   NERVOUS   SYSTEM.  61 

to  c'  and  through  e"  to  s,  and  through  e  e  to  rn  m,  producing  a 
continuous  contraction  of  the  muscles.  But  when  an  impression 
is  made  upon  a/,  an  impulse  is  conveyed  to  c  and  downwards, 
through  e'  to  s.  Now,  the  impulses  conveyed  through  e'  to  s 
may  produce,  when  of  a  certain  degree  of  intensity,  only  an 
arrestive  or  inhibitory  action  on  the  impulses  conveyed  to  s 
through  a  and  e";  while  an  additional  degree  of  intensity 
enables  it  to  pass  through  s  and  e  e  to  m  on,  and  to  produce 
clonic  muscular  contractions.  It  is  also  probable  that  the  cere- 
brum may  exercise  both  an  inhibitory  and  excitative  action  on 
the  cerebellum  through  the  intercentral  fibres  (i),  which  connect 
the  centres  directly  with  each  other.  This  hypothesis  was  first 
stated  by  Dr.  Hughlings  Jackson,  and  he  has  since  applied  it, 
with  his  usual  subtilty  and  generalising  power,  to  the  explanation 
of  various  pathological  phenomena.  As  this  is  an  exceedingly 
important  theory,  it  will  be  as  well  to  illustrate  the  actions  of 
the  cerebrum  and  cerebellum  by  reference  to  the  muscular  con- 
tractions necessary  for  the  maintenance  of  the  erect  posture  and 
for  locomotion. 

§  28. _T?ie  Erect  Posture. — In  the  erect  posture  the  weight  of 
the  body  is  borne  by  the  plantar  arches,  and  the  body  is  main- 
tained by  a  series  of  muscular  contractions  in  such  a  position 
that  the  line  of  gravity  falls  within  the  area  of  the  feet.  In 
this  position  the  line  of  gravity  of  the  head  falls  in  front  of  the 
occipital  articulation ;  that  of  the  combined  head  and  trunk 
passes  behind  a  line  joining  the  two  hip  joints ;  that  of  the 
combined  head,  trunk,  and  thighs  falls  a  little  behind  the  knee 
joints ;  and  the  line  of  gravity  of  the  whole  body  passes  in  front 
of  the  line  drawn  between  the  two  ankle  joints.  This  statement 
of  the  direction  of  the  line  of  gravity  shows  that  when  the  foot 
is  made  the  surface  of  support,  the  body  would  fall  forwards 
unless  prevented  by  contraction  of  the  muscles  of  the  calf 
{Fig.  7,  I).  "  But  this  action,"  says  Professor  Huxle}^^  "  tends  to 
bend  the  leg,  and  to  neutralise  this  and  keep  the  leg  straight 
the  great  muscles  in  front  of  the  thigh  {Fig.  7,  2)  must  come 
into  play.    But  these,  by  the  same  action,  tend  to  bend  the  body 

'  Huxley  (T.  H.).  Lessons  in  Elementary  Physiology.  Fourth  edition.  Lend., 
1870.    p.  14. 


62 


Fig.  7. 


STEUCTURE  AND  FUNCTIONS 

forward  on  the  legs ;  and  if  the  body  is  to 
be  kept  straight  they  must  be  neutralised 
by  the  action  of  the  muscles  of  the 
buttocks  and  of  the  back  {Fig.  7,  III)." 
It  will  be  seen,  however,  that  since  the 
centre  of  gravity  of  the  combined  head 
and  trunk  falls  a  little  behind  the  line 
joining  the  hips,  the  muscles  of  the 
buttocks,  although  strongly  contracted  in 
effecting  the  erect  position,  do  not  require 
to  contract  in  order  to  maintain  it. 

The  muscles  of  the  calf,  those  of  the 
front  of  the  thigh,  and  the  erector  spinas 
are  therefore  the  most  active  muscles  in 
maintaining  the  erect  posture  ;  and  these 
are,  according  to  the  hypothesis,  main- 
tained in  a  state  of  tonic  contraction, 
mainly  by  the  cerebellum. 


Fig.  7  (after  Huxley).  Dia- 
gram illustrating  the  at- 
tachments of  some  of  the 
most  important  muscles 
which  keep  the  body  in 
the  erect  posture.  I, 
Muscles  of  the  Calf, 
II,  Those  of  the  back  of 
the  Thigh.  Ill,  Those 
of  the  Spine,  which  tend 
to  keep  the  body  from 
falling  forward.  1,  the 
Muscles  of  the  front  of 
the  Leg ;  2,  those  of  the 
front  of  the  Thigh;  3, 
those  of  the  front  of  the 
Abdomen;  4,  5,  those  of 
the  front  of  the  Neck, 
which  tend  to  keep  the 
body  from  falling  back- 
wards. The  arrows  in- 
dicate the  direction  of 
action  of  the  muscles, 
the  foot  being  fixed. 


§  29.  WalJcing. — At  each  step  in  walk- 
ing there  is  a  moment  at  which  the  body 
rests  vertically  on  the  foot  of  one  leg  (say 
the  right),  which  is  then  called  the  "active 
leg,"  The  other  (left),  which  is  now  called 
the  " i^assive  leg"  is  at  this  time  inclined 
obliquely,  with  the  heel  raised  and  the 
toe  resting  on  the  ground.  The  left  leg, 
slightly  flexed  to  avoid  contact  with  the 
ground,  is  now  swung  forward  like  a  pen- 
dulum, the  length  of  the  swing  or  step 
being  determined  by  the  length  of  the  leg, 
the  left  toe  is  brought  to  the  ground,  and 
the  step  is  finished.  The  left  leg,  which 
was  previously  passive,  now  gradually 
becomes  straight  and  rigid,  and  the  body 
is  moved  forward  on  the  left  toe  as  a 
fulcrum ;  while  the  right  leg,  which  was 
previously  active,  assumes  an  inclined 
position,  with  the  heel  raised  and  the  toe 


OF   THE  NERVOUS   SYSTEM.  63 

resting  on  the  ground,  so  that  it  is  ready  to  swing  forwards,  and 
then  once  more  to  assume  the  role  of  activity,  while  its  fellow 
becomes  in  its  turn  passive  again.  During  the  forward  move- 
ment the  centre  of  gravity  of  the  body  describes  a  curve,  the 
convexity  of  which  is  upward ;  hence  in  successive  steps  the 
centre  of  gravity,  and  with  it  the  top  of  the  head,  describes  a 
series  of  curves,  with  their  convexities  upwards. 

In  standing  on  both  feet  the  line  of  gravity  falls  between 
them ;  but  in  walking  it  must  be  alternately  shifted  from  one 
foot  to  the  other,  in  order  to  balance  the  body  on  the  active  leg. 
While  the  left  leg,  for  instance,  is  passive  and  swinging,  the  line 
of  gravity  falls  within  the  area  of  the  right  foot,  and  passes 
through  the  right  lateral  half  of  the  pelvis,  and  as  the  left  foot 
becomes  active  the  centre  of  gravity  is  shifted  to  the  opposite 
side,  and  the  line  of  gravity  passes  through  the  left  lateral  half 
of  the  pelvis  to  the  left  foot.  In  walking,  therefore,  the  centre 
of  gravity  describes  not  only  a  series  of  vertical  but  also  a  series 
of  horizontal  curves,  so  that  the  curve  described  by  the  head  is 
composed  of  vertical  and  horizontal  factors.  In  slow  walking 
there  is  an  appreciable  time  during  which  both  feet  are  on  the 
ground ;  the  one  being  planted  so  as  to  become  active  before  the 
other  has  ceased  its  activity.  In  fast  walking  this  period  is  very 
short,  the  one  leaving  the  ground  the  moment  the  other  touches 
it ;  while  in  running  there  is  an  interval  during  which  neither 
feet  are  on  the  ground. 

Let  us  now  attend  to  the  muscles,  the  contraction  of  which 
effects  the  changes  of  attitude  necessarily  involved  in  walking. 
Suppose  that  we  start  with  the  right  leg  in  the  vertical  position, 
with  the  line  of  gravity  passing  within  the  line  of  the  right  foot, 
and  the  left  partially  raised  from  the  ground.  The  first  indica- 
tion of  a  forward  movement  must  be  effected  by  a  contraction 
of  the  flexors  of  the  foot  on  the  leg,  which,  as  the  toe  is  fixed, 
bends  the  leg  and  with  it  the  whole  body  forward.  This  con- 
traction fixes  the  upper  end  of  the  tibia,  the  leg  being  bent  for- 
ward at  an  acute  angle  with  the  foot,  and  the  femur  is  kept 
extended  on  the  tibia  by  a  rigid  contraction  of  the  muscles  of  the 
front  of  the  thigh.  The  lower  end  of  the  femur  and  upper  end 
of  the  tibia  are  now  rendered  fixed  points,  the  line  of  gravity  is 
rapidly  passing  forward  from  the  middle  of  the  foot  to  the  toe, 


64  STRUCTURE   AND  FUNCTIONS 

the  weight  is  thus  taken  off  the  heel,  aod  contraction  of  the 
muscles  of  the  calf  causes  its  elevation.  But  the  line  of  gravity 
is  now  passing  through  the  toe,  in  front  of  the  knee,  and  in  front 
of  the  centre  of  the  hip  joint,  so  that  the  muscles  of  the  back  of 
the  thigh  and  those  of  the  buttocks  must  contract  strongly  or  the 
body  would  be  flexed  on  the  thighs,  while  the  erectors  of  the 
spine  must  be  sufficiently  contracted  to  keep  the  different  seg- 
ments of  the  body  in  a  rigid  condition.  It  is  manifest  that,  as 
soon  as  the  line  of  gravity  passes  in  front  of  the  centre  of  the 
hip  joint  and  through  the  toe,  although  muscular  action  may 
maintain  the  different  segments  of  the  body  extended,  no  mus- 
cular action  can  prevent  the  body  as  a  whole  from  falling  forward 
on  the  toe  as  a  pivot,  and  the  body  would  fall  unless  the  left  foot 
were  now  in  a  position  to  be  planted  on  the  ground  in  front  of 
the  line  of  gravity,  and  ready  to  assume  the  role  of  the  active 
leg.  Before,  however,  the  left  leg  can  become  active,  the  line  of 
gravity  must  be  transferred  to  the  left  foot,  and  before  the  right 
foot  can  be  made  to  swing  it  must  be  shortened  so  as  to  avoid 
contact  with  the  ground.  These  operations  are  so  important  as 
to  require  careful  study. 

§  30.  The  transference  of  the  centre  of  gravity  from  the 
passive  to  the  active  leg  is  largely  effected  by  the  contraction  of 
the  abductors  of  the  thigh,  and  especially  by  the  gluteus  medius, 
contraction  of  which,  the  left  thigh  being  fixed,  causes  the 
pelvis  to  rotate  vertically  on  the  hip  joint ;  so  that  the  centre 
of  gravity,  and  with  it  the  head,  describes  a  curve  to  the  left, 
with  its  convexity  upwards,  a  movement  which  at  the  same 
time  slightly  elevates  the  pelvis  and  with  it  the  hip  joint  of  the 
opposite  side.  The  slight  elevation  of  the  right  hip  joint  not 
only  transfers  the  centre  of  gravity  to  the  left,  but  also  in- 
creases the  distance  of  the  centre  of  movement  (hip  joint)  of 
the  passive  leg  (right)  from  the  ground,  and  thus  prepares  for 
the  forward  swinging  of  the  right  leg.  The  contraction  of  the 
abductors  is  accompanied  by  a  contraction  of  their  antagonists — 
the  adductors,  which  not  only  gives  steadiness  to  the  pelvis  but 
holds  the  latter  in  readiness  to  counteract  at  once  any  tendency 
to  over-action  on  the  part  of  the  former,  by  which  the  line  of 
gravity  would  be  carried  beyond  the  middle  of  the  foot.     The 


OF  THE  NERVOUS   SYSTEM,  65 

curve  described  by  the  head  owing  to  contraction  of  these 
rhuscles  would  indeed  be  much  greater  than  it  is  were  it  not 
compensated  by  contraction  of  other  muscles.  At  the  time  that 
the  abductors  of  the  left  leg  contract,  and  thus  rotate  the  pelvis, 
the  centre  of  gravity,  and  head  to  the  left,  the  erector  spinas 
of  the  right  side  enter  into  a  somewhat  additional  contraction 
producing  a  compensating  curve  to  the  right,  so  that  the  head 
does  not  deviate  to  the  left  during  the  transference  of  the  centre 
of  gravity  to  the  left  foot  to  anything  like  the  extent  that  might 
be  expected. 

§  31.  Swinging  of  the  Passive  Leg. — It  has  just  been  said 
that  when  the  left  leg  becomes  active  the  pelvis  rotates  vertically 
on  the  left  hip,  so  that  the  opposite  hip  joint  is  slightly  elevated 
to  an  extent  sufficient  to  take  the  weight  of  the  body  from  the 
right  toe ;  but  inasmuch  as  the  right  foot  is,  at  the  time  it  is 
about  to  become  passive,  extended  obliquely,  with  the  toe  de- 
pressed, while  the  left  is  placed  nearly  vertically,  the  former  is 
much  too  long  to  swing  past  the  other  without  touching  the 
ground,  and  the  slight  vertical  rotation  of  the  pelvis  just 
described  does  not  give  the  requisite  elevation  for  this  purpose. 
In  order  to  swing  forwards,  therefore,  the  right  leg  is  still  further 
shortened  by  flexion  of  its  various  segments  on  the  body  and  on 
one  another.  The  thigh  is  slightly  flexed  on  the  body,  the  leg 
on  the  thigh,  and  the  foot  on  the  leg.  Of  these  movements  the 
slight  elevation  of  the  toe  caused  by  dorsal  flexion  of  the  foot  is 
by  far  the  most  important  and  special;  it  is  this  movement 
which  distinguishes  the  walk  of  the  adult  from  that  of  the  infant, 
the  latter  advancing  the  passive  foot  not  by  a  pendulum  motion, 
but  by  a  voluntary  effort  in  which  the  leg  and  foot  are  raised 
from  the  ground  by  flexion  of  the  thigh  on  the  body.  It  may 
also  be  mentioned  that  the  adductors  of  the  thigh  manifest  a  very 
special  action  in  assisting  to  cross  one  leg  over  the  other — an 
action  which  cannot  be  effected  by  the  lower  animals,  or  by  the 
human  infant,  and  hence  these  muscles  must  also  be  regarded 
as  being  in  an  especial  manner  under  cerebral  influence.  The 
cerebro- spinal  influence  is  therefore  manifested  in  the  active 
leg  during  locomotion  by  securing  a  strong  contraction  of  the 
anterior  flexors  of  the  foot,  and  of  the  flexors  of  the  leg  on  the 
VOL.  I.  F 


66  STRUCTURE  AND   FUNCTIONS 

thigh  along  with  the  abductors  so  as  to  fix  and  rotate  the  pelvis 
vertically ;  while  it  is  manifested  in  the  passive  leg  partly  by 
contraction  of  the  flexors  of  the  thigh  on  the  body,  partly  by 
contraction  of  the  flexors  of  the  leg  on  the  thigh,  and  partly  by 
flexion  of  the  foot  on  the  leg,  the  flexion  in  all  these  instances 
being  probably  due  less  to  active  contraction  than  to  relaxation 
of  the  antagonist  muscles.  The  transference  of  the  line  of 
gravity  to  the  active  leg  also  takes  part  in  this  action  by 
removing  the  fixed  point,  from  which  the  muscles  of  the  passive 
leg  act,  from  the  foot  to  the  pelvis. 

§  32.  The  Act  of  Acquiring  the  Erect  Posture. — ^Now,  if  the 
changes  of  position  which  take  place  in  walking  are  due  to  the 
predominance  of  cerebro-spinal  over  cerebello-spinal  action,  this 
is  no  less  true  with  respect  to  the  successive  changes  of  posture 
requisite  to  raise  the  body  from  the  recumbent  to  the  erect 
posture.  Suppose  a  man  is  lying  in  the  prone  position,  and 
then  gets  up  on  his  hands  and  knees.  When  the  knees  are 
raised  by  muscular  action,  so  that  the  body  is  supported  by  the 
tips  of  the  fingers  and  the  toes,  while  the  centre  of  gravity  falls 
midway  between  the  anterior  and  posterior  extremities,  this 
constitutes  what  I  may  call  the  quadrupedal  position.  In  this 
position  the  toes  constitute  the  fixed  point  for  the  posterior 
extremities,  and  the  muscular  strain  rests  upon  the  flexors  of 
the  phalanges,  their  contraction  being  necessary  to  maintain  the 
rigidity  of  the  plantar  arch.  ,  The  extensors  of  the  foot  on  the 
leg  must  contract  to  prevent  flexion  of  the  leg  at  the  ankle, 
the  extensors  of  the  leg  on  the  thigh  must  contract  in  order  to 
prevent  the  thigh  being  flexed  on  the  leg,  and  the  extensors  of 
the  body  on  the  thigh  must  also  contract  in  order  to  prevent  the 
former  being  flexed  on  the  latter.  A  further  contraction  of  these 
same  muscles  drags  the  centre  of  gravity  of  the  body  upwards 
and  backwards,  the  weight  is  taken  off  the  anterior  extremities, 
and  the  body  assumes  the  semi-bipedal  posture  in  which  the  line 
of  gravity  passes  between  the  feet  in  the  line  which  joins  the 
toes,  considerably  in  front  of  the  line  which  joins  the  ankles, 
behind  that  which  joins  the  knees,  and  in  front  of  that  joining 
the  hip  joints.  It  is  manifest  that  the  contractions  of  the 
muscles  of  the  sole,  those  of  the  calf,  front  of  the  thigh,  those  of 


OF  THE  NERVOUS  SYSTEM.  67 

the  gluteal  regioa  and  the  erectors  of  the  spine,  must  largely 
predominate  over  their  antagonists  in  order  to  maintain  this 
position,  and  that  this  predominance  must  be  maintained  until 
such  time  as  the  heel  touches  the  ground,  when  the  line  of 
gravity  passes  from  the  toes  to  the  centre  of  the  plantar  arch,  and 
behind  the  line  joining  the  centre  of  the  two  hip  joints.  The 
vertical  position  is  then  maintained  mainly  by  means  of  the  bones 
and  ligaments,  aided  only  by  a  slight  degree  of  muscular  contrac- 
tion. Now,  the  bipedal  erect  posture  has  only  been  attained 
from  the  recumbent  position  by  passing  through  an  infinity  of 
intermediate  postures ;  and  according  to  the  hypothesis  the 
cerebello-spinal  system  has  had  to  maintain  each  posture  attained 
by  striking  a  balance  between  the  tensions  of  the  extensors  and 
flexors  of  the  body,  the  latter  being  aided  by  gravity ;  while  the 
cerebro-spinal  system  continually  changes  each  attained  posture 
by  overthrowing  this  balance  in  favour  of  the  extensors.  In 
passing  from  the  bipedal  erect  posture  through  the  semi-bipedal 
and  quadrupedal  to  the  recumbent  posture  a  reverse  process 
takes  place,  the  cerebro-spinal  system,  at  each  new  position 
acquired,  inhibits  the  action  of  the  cerebello-spinal  system  on 
the  extensors,  so  that  contraction  of  the  flexors  assisted  by 
gravity  is  allowed  gradually  to  predominate. 
,  But  if  this  hypothesis  of  the  joint,  although  opposite,  action 
of  the  cerebrum  and  cerebellum  acting  through  the  spinal  cord 
be  true  at  all,  it  must  be  accepted  in  its  fullest  extent.  If,  for 
instance,  it  be  true  that  the  passage  from  what  I  have  called  the 
quadrupedal  to  the  bipedal  posture  in  the  human  subject  is  due 
in  the  individual  to  the  predominance  of  cerebral  influx  to  the 
extensors  over  their  antagonists,  this  is  no  less  true  with  respect 
to  the  race.  In  the  gradual  development  of  man  from  the  lower 
animals  the  same  forces  have  been  at  work.  From  the  semi- 
bipedal  position  assumed  by  a  dog  attempting  to  stand  on  its 
hind  legs,  and  the  imperfect  bipedal  attitude  of  the  monkey  to 
the  perfect  bipedal  posture  of  man,  the  transition  must  have 
been  effected  by  the  gradual  predominance  of  the  extensors  over 
their  antagonists  through  cerebro-spinal  influence.  In  all  these 
processes  it  will  be  seen  that  the  flexors  of  the  body  are  aided 
in  their  action  by  the  force  of  gravitation,  while  the  extensors 
have  to  overcome  this  force  by  their  action ;  hence  the  latter 


68  STRUCTURE  AND  FUNCTIONS 

must  be  capable  of  much  more  powerful  contraction  than  the 
former,  and  are  consequently  more  liable  to  have  more  powerful 
discharges  sent  to  them  both  from  the  cerebro -spinal  and 
cerebello-spinal  systems. 

When,  therefore,  both  the  extensors,  and  flexors  of  the  head, 
trunk,  and  lower  extremities  are  contracted  to  their  utmost 
capacity,  the  action  of  the  former  must  predominate  over  that 
of  the  latter  ;  so  that  the  segments  of  the  lower  extremities  will 
be  extended  upon  one  another,  and  the  body  will  be  arched  with 
the  concavity  directed  backwards,  as  occurs  during  the  paroxysms 
of  tetanus.  But  the  hand  being  mainly  an  organ  of  prehension, 
the  principal  function  of  the  anterior  limbs  of  man  is  to  pull 
objects  towards  the  trunk,  the  latter  being  the  fixed  point  during 
their  activity  ;  hence  the  flexors  of  the  upper  extremities  must 
be  more  strongly  developed  than  the  extensors.  And  when  the 
hands  become  fixed,  as  in  climbing,  the  most  powerful  contrac- 
tions are  obtained  when  they  are  in  a  position  to  drag  the  body 
towards  the  fixed  position,  and  not,  as  in  the  case  of  the  lower 
extremities,  when  the  body  is  thrust  upwards  and  away  from  it ; 
hence,  when  the  muscles  of  the  upper  extremities  are  contracted 
to  their  utmost  capacity,  flexion  will  predominate  over  extension. 

§  33.  Fundamental  and  Accessory  portions  of  the  Nervous 
System. — Before  leaving  this  portion  of  our  subject  I  should 
like  to  establish  one  more  distinction.  Structure  being  the 
correlative  of  function,  the  multiplicity  and  complexity  of  the 
movements  which  distinguish  man  from  the  lower  animals 
must  be  accompanied  by  a  corresponding  degree  in  the  intricacy 
and  variety  of  the  structural  arrangements  of  his  nervous  system. 
The  main  movements  which  distinguish  man  from  the  lower 
animals  are  those  concerned  in  attaining  and  maintaining  the 
erect  posture,  the  varied  movements  of  the  hands  as  organs  of 
prehension,  the  movements  of  voice  and  articulation  concerned 
in  speech,  and  those  which  are  active  in  the  production  of  facial 
expression.  All  these  movements  must,  therefore,  be  represented 
in  the  human  nervous  system  by  structural  arrangements  super- 
added to  those  which  man  possesses  in  common  with  the  highest 
of  the  lower  animals.  Indeed  all  the  complex  movements  first 
mentioned  are  acquired  considerably  after  the  birth  of  the  human 


OF  THE  NERVOUS  SYSTEM.  69 

infant,  and  we  may  consequently  expect  that  the  structural 
arrangements  corresponding  to  them  either  do  not  exist  at  birth 
or  exist  only  in  an  embryonic  condition. 

The  portions  of  the  nervous  system  which  man  possesses  in 
common  with  the  lower  animals,  and  which  are  well  developed 
in  the  human  embryo  at  nine  months,  I  shall  call  the  funda- 
mental  part ;  and  the  portions  which  have  been  superadded  in 
the  course  of  evolution,  which  differentiate  the  nervous  system 
of  man  from  that  of  the  highest  of  the  lower  animals,  and 
which  are  either  absent  in  the  human  embryo,  or  exist  only  in 
an  embryonic  condition,  I  shall  call  the  accessory  part  of  the 
nervous  system. 

The  fundamental  portion  of  the  human  nervous  system 
co-ordinates  the  fundamental  functions  which  man  possesses  in 
common  with  the  lower  animals ;  but  the  accessory  portions 
can  only  be  said  to  regulate  the  accessory  functions  in  a  peculiar 
sense.  The  accessory  structure  constitutes  indeed  a  new  com- 
plexity of  mechanism  superadded  to  that  already  existing,  a 
complexity  rendered  necessary  for  the  regulation  of  the  intricate 
and  multiform  actions  which  distinguish  man  from  the  lower 
animals.  In  the  development  of  the  accessory  system,  small 
round  cells  and  non-medullated  fibres  appear  at  a  comparatively 
late  period  in  the  development  of  the  embryo,  and  the  presence 
of  these  simple  elements  may  be  regarded  as  the  structural 
counterpart  of  a  new  modification  or  specialisation  of  function. 
Specialisation  of  function  has  hitherto  been  connected  with  the 
gradual  development  of  medullated  from  non-medullated  fibres, 
and  of  large  caudate  from  small  round  cells  ;  but  now  it  appears 
that  specialisation  of  function  is  to  be  connected  with  the 
development  of  embryonic  cells  and  fibres.  There  is,  however, 
no  contradiction  between  the  two  statements.  The  embryonic 
cells  and  fibres  of  the  accessory  system  do  not  of  themselves 
indicate  any  specialisation  of  function.  These  cells  and  fibres 
are,  indeed,  mere  complications  of  an  already  existing  mechanism, 
and  it  is  this  alone  which  entitles  them  to  be  regarded  as  true 
indicators  of  a  newly-acquired  specialisation  of  function ;  they 
are,  in  short,  mere  modifications  of  an  already  existing  structure 
corresponding  to  newly -acquired  modifications  of  previously 
existing  muscular  adjustments.     There  can  be  no  doubt  that 


70  STEUCTUEE  AND  FUNCTIONS 

the  fundamental  and  accessory  portions  of  the  nervous  system 
will  be  so  mingled  together  that  it  will  be  almost  impossible  to 
separate  the  two ;  but  whether  they  can  be  distinguished  from 
one  another  morphologically  or  not,  the  mental  distinction  is 
a  valuable  one,  and  it  is  important  to  remember  that  in  man 
both  the  cephalic  ganglia,  the  central  grey  tube,  the  conducting 
paths  which  connect  them  with  one  another,  and  even  the 
peripheral  nerves  themselves,  must  contain  fundamental  and 
accessory  cells  and  fibres. 

§  34.  The  Law  of  Evolution. — We  have  now  passed  very 
rapidly  and  very  imperfectly  under  review  the  fundamental 
laws  of  nervous  structure  and  function.  We  have  seen  that  the 
nervous  system  consists  essentially  of  cells  and  fibres,  that  the' 
cells  are  first  small,  round,  and  uniform,  that  they  gradually 
become  large  and  assume  numerous  processes,  that  the  fibres 
are  at  first  small  fibrils  which  together  form  larger  fibres,  that 
these  become  complicated  by  assuming  an  elastic  sheath,  and 
still  further  complicated  by  assuming  a  second  sheath  of  a  very 
special  character.  We  have  seen  how  the  fibres  come  to  be 
packed  together  to  form  white  cords  and  the  cells  to  form  small 
masses  of  grey  substance  termed  ganglia ;  how  the  cords  inte- 
grate to  form  thick  masses  of  white  substance  and  the  small 
ganglia  to  form  masses  of  ganglionic  grey  substance,  and  how 
this  continuous  process  assumed  a  still  more  complicated  form 
when  some  of  the  ganglia  became  subordinate,  while  others 
exercised  superordinate  functions.  The  whole  of  the  intricate 
processes  here  described  illustrate  the  one  great  law  of  evolu- 
tion. That  law  may  be  described  as  a  progressive  integration 
both  of  structure  and  function,  during  which  there  is  a  passage 
from  the  uniform  to  the  multiform,  from  the  simple  to  the  com- 
plex, and  from  the  general  to  the  special  (Spencer^).  During 
the  evolution  of  the  nervous  system  of  man  the  fundamental 
portion  is  first  developed.  The  nervous  system  of  man  is  at  first 
similar  to  that  possessed  by  all  animals  which  possess  a  nervous 
system,  or  at  any  rate  all  those  which  are  sufiiciently  elevated  to 
possess  a  spinal  cord ;  but  as  development  proceeds  the  nervous 
system  of  man  becomes  gradually  differentiated  from  that  of  an' 
1  Spencer  (Mr.  Herbert).    First  Principles.    Third  edition,  1870,  p.  278. 


OF  THE  NERVOUS   SYSTEM.  71 

ever-increasing  number  of  the  lower  animals,  while  still  main- 
taining a  general  likeness  to  the  nervous  system  of  the  higher 
animals  up  to  the  time  of  birth.  This,  then,  constitutes  the 
fundamental  portion  of  the  nervous  system  of  man ;  but  after 
birth  the  accessory  portion,  which  up  till  this  time  only  appears 
in  a  rudimentary  condition,  now  undergoes  progressive  develop- 
ment, and  the  nervous  system  of  man  becomes  gradually 
differentiated  from  that  of  all  other  animals.  It  will  thus  be 
seen  that  the  fundamental  portion  is  first  developed,  and  that 
the  superaddition  of  the  accessory  portion  greatly  increases  the 
multiformity,  the  complexity,  and  the  speciality  of  the  human 
nervous  system,  and  that  it  is  the  latest  product  of  its  evolution. 

§  35.  Laiu  of  Dissolution. — We  must  now  proceed  to  regard 
the  phenomena  of  the  structure  and  function  of  the  nervous 
system  from  a  new  and  opposite  standpoint.  We  must  watch 
the  cells  lose  their  processes,  and  from  the  multiformity  of  the 
caudate  cells  with  numerous  processes  pass  to  the  uniformity  of 
the  round  cells  destitute  of  processes :  we  must  observe  the  fibres 
losing  their  medullary  sheath,  then  their  elastic  sheath,  and 
finally  the  axis  cylinder  itself  becoming  disorganised,  so  that  the 
nervous  tissue  gradually  gives  place  to  a  simple  and  uniform 
connective  tissue :  we  must  observe  accompanying  this  process  a 
corresponding  loss  of  function,  in  which  the  complex  movements 
that  characterise  health  become  difficult  or  impossible :  in  one 
word,  we  must  trace  the  records  of  a  process  in  which  the  pro- 
gressive integration  of  evolution  gives  place  to  a  progressive 
disintegration,  during  which  the  phenomena  of  structure  and 
function,  instead  of  passing  from  the  uniform  to  the  multiform, 
from  the  simple  to  the  complex,  and  from  the  general  to  the 
special,  manifest  a  reverse  tendency,  of  passing  from  the  multiform 
to  the  uniform,  from  the  complex  to  the  simple,  and  from  the 
special  to  the  general.^  The  law  which  governs  this  process  is 
the  law  of  dissolution,  and  it  is  the  great  law  which  regulates  the 
phenomena  of  disease  of  the  nervous  system,  just  as  evolution  is 
the  great  law  which  regulates  its  growth  and  development. 

It  is  scarcely  necessary  to  add  that  the  phenomena  of  evolution 
manifested  in  the  growth  and  development  of  the  organism  are 

'  Spencer.    Ibid.    p.  518. 


72  THE  NERVOUS   SYSTEM. 

exceedingly  gradual  and  continuous,  and  consequently  the  opera- 
tion of  the  law  of  evolution  can  very  readily  be  traced.  Disease 
being,  however,  often  sudden  and  violent  in  its  onset,  striking  at 
times  at  the  fundamental,  at  other  times  at  the  accessory  portions 
of  the  nervous  system,  now  producing  its  baneful  influence  at  one 
stroke,  again  acting  fitfully,  and,  only  on  rare  occasions,  in  a 
gradual  and  progressive  manner,  it  may  be  inferred  that  the 
operation  of  the  law  of  dissolution  can  never  be  so  clearly  traced 
amongst  morbid  phenomena  as  that  of  evolution  in  the  develop- 
ment of  the  organism.  Nevertheless,  there  are  some  diseases  of 
the  nervous  system  which  are  gradual  in  their  invasion  and 
progressive  in  their  course,  and  in  them  the  operation  of  this  law 
is  clearly  visible,  and  it  is  astonishing  how  glimpses  of  the  law 
may  be  obtained  even  when  the  disease  is  sudden  in  its  onset 
and  rapid  in  its  progress.  One  important  corollary  may  be 
drawn  from  what  has  been  said  :  that  as  the  accessory  portion  of 
the  nervous  system  is  the  last  to  be  developed,  it  is  the  portion 
which  is  most  liable  to  become  diseased.  Several  reasons  might 
be  given  why  this  should  be  the  case,  but  these  will  appear  in 
the  subsequent  pages.  It  will  suffice  at  present  to  say  that  the 
accessory  portion,  from  the  late  period  of  its  development,  is  less 
stable  than  the  fundamental  portion,  and  that  its  necessarily 
frail  structure  renders  it  more  liable  to  suffer  both  from  accident 
and  the  inroads  of  disease. 


73 


CHAPTER  II. 


GENERAL    ETIOLOGY. 

The  causes  of  disease  of  the  nervous  system  are  the  same  as 
those  of  disease  of  any  other  part  of  the  body ;  hence  they  do 
not  require  to  be  discussed  at  any  great  length  at  present. 
Whatever  injures  the  protoplasm  of  any  of  the  other  cells  of 
the  body  will  injure  the  protoplasm  of  the  cells  of  the  nervous 
system ;  and  whatever  crushes  or  ruptures  the  cell  wall,  the 
intercellular  substance,  and  fibres  of  other  cells  and  tissues  will 
have  a  similar  effect  upon  the  cell  walls,  the  processes,  and  fibres 
of  the  nervous  system.  But  a  tissue  which  is  so  highly  specialised 
as  the  nervous  tissue  will  be  specially  acted  upon  by  common 
causes  ;  hence  it  is  necessary  to  allude  briefly  to  a  few  of  the 
more  ordinary  causes  of  nervous  disease.  Various  classifications 
of  causes  might  be  adopted,  but  the  most  convenient  one  is  that 
which  divides  them  into  (1)  Intrinsic  and  (2)  Extrinsic  :  the 
former  depending  upon  the  individual  in  whom  the  conditions 
of  disease  are  inherited  or  acquired,  and  the  latter  embracing 
the  external  incident  forces  which  induce  disease. 

§  36.  Intrinsic  Causes. 

(1)  Hereditary  Predisposition. — Some  individuals  inherit  a 
predisposition  to  certain  diseases  of  the  nervous  system.  The 
predisposition  to  a  particular  disease  may  be  special  and 
direct  or  general  and  indirect.  There  suffers,  for  instance, 
from  neuralgia,  at  a  particular  time  of  life,  a  lady  whose  mother 
had  similarly  suffered  at  a  corresponding  age.  In  this  case  the 
transmission  of  the  affection  is  direct  from  mother  to  daughter, 
and  the  transmitted  disease  is  limited  to  a  particular  affection. 
But  the  inheritance  is  not  only  direct  and  special,  it  is  also 
immediate ;  inasmuch  as  the  disease  is  supposed  to  be  trans- 


74  GENERAL  ETIOLOGY. 

mitted  from  parent  to  child.  But  in  a  large  number  of  diseases 
the  inheritance  is  remote,  the  transmitted  affection  being  derived 
not  immediately  from  the  parent,  but  from  a  grandparent,  or 
a  still  more  remote  ancestor.  The  phenomena  of  atavism  or 
reversion,  as  the  remote  inheritance  is  called,  are,  indeed,  very- 
conspicuous  in  the  transmission  of  a  large  number  of  hereditary 
nervous  diseases. 

In  other  cases  the  disease  is  not  directly  inherited,  but  an 
unstable  nervous  system  is  transmitted  in  which  either  neu- 
ralgia or  some  other  disease  of  the  nervous  system  is  readily 
induced  by  slight  external  causes.  In  such  cases  a  neuropathic 
tendency  or  a  neurotic  disposition  is  transmitted,  which  renders 
the  nervous  system  exceedingly  vulnerable.  In  these  cases  the 
tendency  to  any  particular  disease  is  indirect,  and  it  is  also 
general,  inasmuch  as  one  member  of  the  family  may  suffer  from 
neuralgia,  another  from  chorea,  paralysis,  hysteria,  epilepsy,  or 
insanity,  while  others  manifest  a  tendency  to  uncontrollable 
alcoholic  excesses.  The  predisposition  to  nervous  disease  is  still 
more  indirect  at  other  times.  One  man  dies  of  disease  of  the 
brain,  as  his  father  died  before  him,  at  a  particular  age,  but  it 
is  because  both  have  inherited  gout  which  has  induced  early 
arterial  degeneration,  which  in  its  turn  has  ended  in  rupture  of 
a  vessel  in  the  brain,  resulting  in  sudden  death.  In  another 
family  several  children  in  succession  die  in  the  midst  of  con- 
vulsions followed  by  coma,  but  it  is  because  they  have  inherited 
a  strong  tendency  to  tubercular  disease,  and  not  from  inherent 
weakness  of  the  nervous  system. 

(2)  Age. — The  age  of  the  patient  exercises  a  powerful  effect 
upon  the  predisposition  to  certain  diseases.  Some  diseases  of 
the  nervous  system  are  peculiarly  liable  to  occur  in  childhood. 
So  much  is  this  the  case  in  a  certain  form  of  spinal  paralysis 
that  it  has  been  called  infantile  spinal  paralysis,  even  although 
essentially  the  same  disease  occurs  in  adults ;  and  it  is  notorious 
to  everyone  how  very  liable  children  are  to  be  attacked  with 
convulsions  in  comparison  with  adults.  Other  diseases,  like 
hysteria  and  probably  neuralgia  also,  very  generally  manifest 
themselves  for  the  first  time  during  the  period  of  sexual  develop- 
ment, while  others  are  apt  to  come  on  during  the  period  of 
sexual  decline. 


GENERAL   ETIOLOGY.  75 

(3)  Sex. — Females  are  more  liable  to  certain  affections  than 
males,  while  the  converse  of  this  rule  also  holds  good.  Hysteria, 
for  instance,  although  by  no  means  limited  to  the  female  sex, 
occurs  with  such  relative  frequency  in  women  that  it  was  at  one 
time  supposed  to  be  always  due  to  some  uterine  derangement. 
Trigeminal  neuralgia  is  much  more  frequently  met  with  in 
females  than  males ;  while  sciatica,  on  the  other  hand,  occurs 
more  frequently  in  males,  probably  owing  to  their  being  more 
exposed  to  its  exciting  causes, 

,  (4)  Race. — The  influence  which  race  exerts  in  the  production 
of  nervous  diseases  is  not  well  known,  but  there  can  be  no 
doubt  that  the  civilised  races  of  mankind  are  more  liable  to 
nervous  affections  than  the  less  civilised  races.  And  this  is  only 
what  might  be  expected.  The  complex  conditions  of  civilisa- 
tion require  the  organisation  of  a  more  and  more  complex 
nervous  system  in  the  individual  living  amongst  these  conditions ; 
and  during  the  development  of  this  complexity  the  mechanism 
is  apt  to  break  down  at  some  part, 

(5)  General  N'utritive  Disorders  produce  a  strong  predis- 
position to  nervous  disease.  All  diseases  attended  with  anaemia 
and  cachexia  depress  the  nutrition  of  the  nervous  system  ;  hence 
the  deleterious  effect  of  loss  of  blood,  chronic  disturbances  of 
digestion,  and  severe  and  protracted  acute  disease, 

(6)  Sexual  Excesses  and  Irregularities  exercise  a  very 
depressing  effect  upon  the  nutrition  of  the  nervous  system,  and 
are  consequently  powerful  predisposing  causes  of  different 
nervous  affections,  such  as  neuralgia,  various  organic  diseases  of 
the  spinal  cord,  hysteria,  hypochondriasis,  and  even  the  graver 
psychoses.  The  effects  of  onanism  are  generally  supposed  to  be 
more  injurious  than  those  which  follow  excessive  natural  indul- 
gence, although  this  has  not  yet  been  proved  beyond  doubt. 
There  can  be  no  doubt,  however,  that  frequently  repeated 
onanism,  practised  for  a  succession  of  years,  and  associated,  as 
such  practice  generally  is,  with  habitual  pollutions,  must  strongly 
predispose  to  grave  nervous  diseases.  Illegitimate  sexual  indul- 
gence, either  in  the  natural  way  or  by  onanism,  has  a  degrading 
effect  on  the  moral  nature,  inasmuch  as  the  subject  is  conscious 
that,  were  his  secret  known,  his  conduct  would  excite  the 
greatest  disapprobation  and  aversion. 


76  general  etiology. 

§  37.  Extrinsic  Causes. 

(1)  Traumatic  Influences  are  the  simplest  and  most  direct 
cause  of  nervous  disease.  Wounds,  contusions,  or  lacerations 
may  injure  the  peripheral  nerves,  the  spinal  cord,  or  the  brain, 
and  give  rise  to  the  most  complicated  sensory  motor,  vaso-motor, 
secretory,  and  nutritive  affections,  according  to  the  extent  and 
locality  of  the  lesion. 

(2)  Slow  Compression  of  nervous  tissues  by  pathological 
growths  may  also  gradually  injure  any  part  of  the  nervous  system, 
and  thus  give  rise  to  various  combinations  of  symptoms. 

(3)  Direct  loroiKigation  of  neigJibouring  morhid  processes 
also  frequently  gives  rise  to  severe  affections.  Transverse 
myelitis,  set  up  as  a  sequel  of  disease  of  the  vertebrae,  may  be 
mentioned  as  an  example. 

(4)  Exposure  to  Cold  is  a  frequent  cause  of  disease  of  the 
nervous  system,  its  injurious  effect  being  greatly  increased  when 
it  is  combined,  as  is  frequently  the  case,  with  excessive  fatigue, 
want  of  nourishment,  or  other  depressing  circumstances.  Severe 
disease  of  the  nervous  system,  like  tetanus,  for  instance,  is  very 
apt  to  arise  in  military  campaigns  during  winter,  when  soldiers 
are  often  exposed  to  extreme  cold  after  the  heat,  excitement, 
and  fatigue  of  a  great  battle.  Exposure  to  cold  and  damp,  with 
insufficient  food — conditions  which  are  only  too  frequently  com- 
bined in  the  cellar  livings  and  back -slums  of  our  large  towns — is 
a  prolific  source  of  disease  of  the  nervous  system. 

(5)  Disturbances  of  Circulation,  caused  by  the  suppression 
of  the  menses  or  of  hsemorrhoidal  discharge,  arterial  fluxion,  and 
venous  congestion,  vaso-motor  disturbances,  embolism,  throm- 
bosis, atheroma  of  the  arteries,  and  various  other  conditions,  may 
be  reckoned  amongst  the  exciting  causes  of  nervous  disease. 

(6)  Excessive  exertion,  followed  as  it  is  by  exhaustion,  is  a 
powerful  exciting  cause  of  disease  of  the  nervous  system,  and 
becomes  all  the  more  powerful  when  it  is  combined  with  defi- 
ciency of  food  and  exposure  to  cold  and  damp. 

(7)  The  local  development  of  various  infective  diseases, 
such  as  tuberculosis  and  syphilis,  is  a  frequent  cause  of  severe 
disease  of  the  nervous  system.  It  is  probable  that  in  both  these 
diseases  the  vessels  and  their  adventitise,  along  with  the  connec- 


GENERAL   ETIOLOGY.  77 

tive  tissue  or  neuroglia,  are  the  primary  seats  of  disease,  and  that 
the  affection  of  the  nervous  elements  is  purely  secondary  ;  but 
the  symptoms  do  not  differ  from  those  which  would  be  produced 
by  a  primary  affection  of  the  nervous  elements. 

Grave  diseases  of  the  nervous  system  often  arise  in  connection 
with  the  exanthemata,  typhoid,  and  other  continued  fevers, 
pneumonia,  and  other  acute  inflammations,  or  as  the  result  of 
malaria. 

(8)  Chemical  Poisons  of  various  kinds  cause  disease  of  the 
nervous  system;  many  of  these  act  upon  nervous  tissue  more  or 
less  directly,  while  others  appear  to  influence  it  indirectly. 
Among  the  poisons  which  produce  the  most  deleterious  effects 
upon  the  nervous  system  are  strychnine,  arsenic,  phosphorus, 
mercury,  and  lead.  The  human  organism  has  become,  through 
successive  generations,  so  adapted  to  the  use  of  ethyl  alcohol  as 
an  article  of  diet,  and  as  a  means  of  increasing  social  enjoyment, 
that  it  probably  now  exercises  the  least  deleterious  influence  on 
the  system  of  any  chemical  poison  of  the  same  class.  But  not- 
withstanding this,  the  excessive  consumption  of  alcoholic  drinks, 
which  is  so  common  amongst  all  classes  of  society,  renders  ethyl 
alcohol—the  active  ingredient  of  these  beverages — if  not  the 
most  potent,  at  least  one  of  the  most  important  and  widespread 
of  the  causes  of  disease  of  the  nervous  system. 

Chemical  poisons  are  being  constantly  generated  in  the 
system,  as  the  result  of  normal  disintegrative  processes,  but 
under  healthy  conditions  these  are  eliminated  so  rapidly  by  the 
excretory  organs  that  they  do  not  accumulate  in  sufficient 
quantity  in  the  blood  to  injure  the  nervous  tissues.  When, 
however,  the  normal  excretory  processes  are  diminished  or 
arrested  by  disease,  or  when  an  undue  quantity  of  those  poisons 
is  generated,  serious  nervous  disorder  results.  It  is  not,  there- 
fore, surprising  to  find  that  the  diseases  of  the  lungs,  kidneys, 
and  of  the  other  excretory  organs  are  frequently  accompanied  by 
grave  nervous  symptoms.  The  local  application  of  acids  and 
other  powerful  escharotics  injures  the  nervous  tissues,  as  well  as 
the  other  tissues  of  the  body ;  and  these  agents  are  not  unfre- 
quent  causes  of  disease  of  the  nerve  trunks,  which,  from  their 
position,  are  more  exposed  to  such  injuries  than  the  nerve 
centres. 


78  GENERAL   ETIOLOGY. 

(9)  Local  Irritation  and  Disease  of  the  Viscera,  such  as 
chronic  affections  of  the  kidneys  and  bladder,  chronic  dysentery 
and  other  intestinal  disease,  diseases  of  the  uterus  and  its  ap- 
pendages, peripheral  lesions  of  nerves,  and  chronic  joint  affec- 
tions, are  often  attended  with  spinal  paralysis,  which  was  at  one 
time  thought  to  be  always  of  reflex  origin,  but  in  many  cases 
this  spinal  affection  is  caused  by  an  ascending  neuritis  having 
its  starting  point  in  the  affected  organ. 

(10)  Psychical  Disturbances  are  a  prolific  source  of  disease 
of  the  nervous  system,  and  it  is  probable  that  as  civilisation 
advances  these  causes  will  exercise  a  more  and  more  predominant 
influence  in  the  production  of  nervous  disease.  The  depressing 
passions,  such  as  fright,  alarm,  disgust,  terror,  and  rage,  have  no 
doubt  in  all  ages  exerted  a  deleterious  influence  on  the  nervous 
system ;  but  in  the  present  day  the  keen  competition  evoked  by 
the  struggle  for  existence  in  the  higher  departments  of  social  life 
must  subject  the  latest  evolved  portion  of  the  nervous  system  to 
a  strain  so  great  that  only  those  possessing  the  best  balanced 
and  strongest  nervous  system  can  escape  unscathed. 

(11)  Imitation  of  disease  plays  a  very  important  part  in  the 
causation  of  certain  nervous  affections.  It  is  well  known  that 
hysterical  convulsions  and  chorea,  or  at  least  choreoid  movements, 
often  spread  with  great  rapidity  amongst  girls  at  boarding  schools 
when  one  of  their  number  becomes  once  affected.  An  epidemic 
of  hysterical  clonic  spasms  recently  prevailed  in  a  reformatory 
school  for  girls  in  Manchester  of  so  severe  and  lasting  a 
character  that  a  considerable  number  of  the  inmates  had  to  be 
sent  to  different  hospitals  in  the  town,  and  some  of  them  were 
under  treatment  many  weeks  before  the  spasms  entirely  ceased. 
Even  the  conscious  imitation  of  disease  by  designing  persons 
must  be  regarded  as  a  disorder  of  the  nervous  system  ;  inasmuch 
as  no  one  with  a  well  balanced  and  healthy  nervous  system 
would  resort  to  such  a  degrading  practice. 


79 


CHAPTER  III. 


GENERAL  SYMPTOMATOLOGY. 

GENERAL  CLASSIFICATION  OF  ELEMENTARY  SYMPTOMS. 

The  nervous  system,  taken  as  a  whole,  is  a  mechanism  by 
means  of  which  all  the  actions  of  the  individual  are  brought 
into  relation  with  one  another  and  with  the  actions  of  external 
agents  upon  the  organism,  and  consequently  all  the  diseases 
of  the  nervous  system  may  be  regarded  as  a  disturbance  of 
the  harmony  of  motor  actions,  or,  in  one  word,  as  a  motor 
inco-ordination.  In  a  case  of  cutaneous  and  muscular  anaes- 
thesia of  the  upper  extremity,  for  instance,  the  patient,  unless 
guided  by  the  sense  of  sight,  will  allow  an  object  grasped 
in  the  hand  to  drop ;  or,  in  other  words,  there  is  a  loss  of 
co-ordination  between  the  impressions  made  upon  the  surface 
and  the  muscular  contractions  by  which  a  healthy  organism 
responds.  Nor  is  the  case  different  when  the  absence  of  healthy 
reaction  is  due  to  paralysis  of  the  miiscles,  since  this  also  may 
be  represented  as  a  loss  of  co-ordination  between  atferent  and 
efferent  impulses.  From  this  point  of  view  all  the  diseases  of 
the  nervous  system  may  be  represented  as  disturbances  of  the 
motor  functions  or  as  kinesioneuroses.  This  generalisation  is, 
however,  somewhat  too  sweeping,  since  our  objective  knowledge 
of  disease  extends  not  simply  to  the  actions  of  the  organism 
under  observation,  but  extends  also  to  the  changes  of  form 
induced  by  nutritive  changes,  including  the  alterations  of  secre- 
tion caused  by  disease  of  the  nervous  system.  Our  objective 
knowledge,  therefore,  includes  nutritive  changes  as  well  as  inco- 
ordination of  motor  actions ;  or  embraces  Trophoneuroses  as 
well  as  Kinesioneuroses.     So  far  we  have  spoken  only  of  an 


80  GENERAL   SYMPTOMATOLOGY. 

objective  knowledge,  but  our  acquaintance  witli  disease  does  not 
stop  here,  but  also  includes  a  subjective  knowledge ;  and  if  the 
former  can  be  resolved  into  a  knowledge  of  motor  and  nutritive 
changes,  the  latter  can  be  resolved  entirely  into  a  knowledge 
of  disordered  feeling.  Each  person  can  know  both  his  own. 
diseases,  and  the  diseases  of  others,  only  through  his  feelings, 
and  the  inferences  deduced  from  these  feelings.  And  as  all 
diseases  may  be  resolved  objectively  into  Kinesioneuroses  and 
Trophoneuroses,  so  all  can  be  resolved  subjectively  into  disorder 
of  feeling  or  ^sthesioneuroses.  But  instead  of  maintaining 
this  double  classification  from  two  points  of  view,  the  two 
classifications  are  combined  in  practice ;  so  that  some  symptoms, 
although  made  known  to  us  by  disordered  actions,  are  rapidly 
translated  by  us  into  feeling  and  regarded  subjectively;  while 
other  symptoms,  even  when  only  known  through  feeling,  are 
rapidly  translated  objectively,  and  regarded  as  motor  or  nutritive 
disorders. 

If,  for  instance,  a  slight-  touch  on  the  cutaneous  surface  of  the 
hand  of  a  patient  is  followed  by  numerous  contractions  of  the 
muscles  of  the  extremity,  causing  the  hand  to  be  suddenly  with- 
drawn, and  also  by  contractions  of  the  muscles  of  expiration  and 
of  vocalisation,  inducing  a  loud  cry,  our  immediate  inference  is 
not  that  this  local  impression  was  accompanied  by  an  undue 
amount  of  motor  reaction,  but  that  it  was  accompanied  by  an 
undue  amount  of  sensibility;  the  case  is  regarded  not  as  an 
instance  of  the  Kinesioneuroses  but  of  the  JUsthesioneuroses. 
Suppose,  however,  that  the  observer  himself  is  the  patient,  and 
is  suffering  from  double  vision,  and  that  he  finds  himself  unable 
to  direct  his  right  eye  to  an  object  situated  to  his  right  without 
turning  his  head ;  if  he  is  sufficiently  informed  he  regards  the 
case  not  primarily  as  one  of  sensory  disturbance,  although  this 
is  all  he  can  know  of  it  from  direct  knowledge,  but  as  due  to 
paralysis  of  the  external  rectus  of  the  right  eye ;  in  short,  he 
classifies  the  disease  not  amongst  the  ^sthesioneuroses  but  the 
Kinesioneuroses.  It  is  manifest,  therefore,  that  the  distinction 
between  the  two  classes  of  disease  is  to  a  very  considerable 
extent  arbitrary,  and  that  what  may  be  regarded,  from  one 
point  of  view,  as  a  disorder  of  sensibility  may,  from  another 
point  of  view,  be  regarded  as  a  disorder  of  motor  actions.     And 


GENERAL  SYMPTOMATOLOGY.  81 

if  this  be  true  with  respect  to  the  ^sthesioneuroses  and  the 
Kinesioneuroses,  it  is  no  less  true  with  respect  to  the  Kine- 
sioneuroses  and  the  Trophoneuroses.  Some  forms  of  paralysis, 
for  instance,  are  closely  associated  with  muscular  wasting,  so 
that  both  the  motor  disorder  and  the  trophic  change  are  but 
manifestations  of  one  and  the  same  affection.  Certain  paralyses 
of  peripheral  and  spinal  origin  are  associated  with  atrophy  of  the 
affected  muscles,  and  indeed  I  might  add  of  the  affected  nerves 
also,  so  that  these  affections  could  be  included  amongst  the 
Trophoneuroses  as  well  as  the  Kinesioneuroses.  But  however 
imperfect  may  be  the  classification  which  divides  the  diseases  of 
the  nervous  system  into  sensory,  motor,  and  nutritive  disorders, 
its  practical  utility  overrides  all  theoretical  objections. 

§  38.  yEstkesioneuroses. — As  already  remarked  almost  every 
symptom  of  disease  might  be  included  under  the  term  ^Esthe- 
sioneurosis ;  but  we  purpose  only  to  give  in  this  place  a  very 
general  account  of  the  disorders  of  the  elementary  or  undecom- 
posable  feelings.  The  disorders,  therefore,  of  the  intellectual 
processes  and  of  the  emotions,  both  of  which  are  highly  complex 
combinations  of  the  elementary  feelings,  will  be  left  out  of  account 
for  the  present,  except  so  far  as  they  must  come  incidentally 
under  notice  during  the  consideration  of  the  simple  feelings.  The 
elementary  feelings  comprise,  in  addition  to  those  generated  by 
the  direct  action  of  external  and  internal  stimuli — real  feelings, 
the  revivication  of  those  feelings  in  memory — ideal  feelings,  and 
the  feelings  of  the  simple  relations  of  agreement  and  difference, 
co-existence  and  sequence.  It  is  manifest  that  the  feelings  gene- 
rated by  stimuli  are  the  primary  constituents  of  consciousness, 
the  remaining  feelings  being  secondary  and  derived ;  and  it  is 
with  the  disorders  of  the  primary  elementary  feelings  that  we 
have  chiefly  to  do  here,  whilst  the  disorders  of  the  secondary  ele- 
mentary feelings  will  only  come  under  consideration  in  so  far  as 
they  become  inextricably  blended  with  the  primary  feelings. 

The  primary  elementary  feelings  admit  of  (A)  an  anatomical 
and  (B)  a  physiological  classification. 

(A)  Ano.tomical  Classification. — The  feelings  are  divided  by 
Mr.  Herbert  Spencer^  into  those  which  are  centrally  initiated — 

^  Spencer  (Mr.  H.).    The  Principles  of  Psychology.    Vol.  I.,  1870,  p.  166  tt  seg. 
VOL.  I.  G 


82  GENERAL  SYMPTOMATOLOGY. 

the  emotions,  and  those  which  are  initiated  at  the  periphery  of 
the  body;  the  latter  he  subdivides  into  those  whicli  are  initiated 
by  the  action  of  objects  on  some  part  of  the  external  surface  of 
the  body — the  epi- peripheral  feelings,  and  those  which  are 
initiated  by  internal  actions  and  processes — the  ento-peripheral 
feelings.  But  although  this  classification  is  very  useful,  we  propose 
to  adopt  a  more  simple  one,  as  being  more  suited  to  our  purpose. 
Thus  the  primary  elementary  feelings  may  be  divided  into  (I.) 
the  various  forms  of  cutaneous  sensibility;  (II.)  the  feelings 
whicli  accompany  the  actions  and  changes  of  the  voluntary 
muscles ;  (HI.)  those  associated  with  the  nutrition  and  move- 
ments of  the  bones,  ligaments,  and  joints ;  (IV.)  those  which 
attend  the  various  internal  organic  acts  and  processes ;  and  (V.) 
the  sensations  derived  from  the  special  senses. 

(B)  Physiological  Classification. — The  primary  elementary 
feelings  admit  of  being  divided,  from  the  functional  or  physio- 
logical standpoint,  into  (I.)  the  common,  subjective,  or  emotional 
feelings  (pleasures  and  pains) ;  and  (II.)  the  special,  objective,  or 
intellectual  feelings  (sensations,  perceptions,  cognitions). 

(I.)  The  Common  or  Subjective  Feelings  :  Pleasures  and 
Pains. — When  one  of  our  fingers  is  pricked  by  a  pin  we  im- 
mediately experience  a  painful  feeling.  We  may  go  so  far  as  to 
localise  the  feeling  in  the  injured  finger,  but  we  refer  the 
sensation  to  our  senses  and  not  to  the  external  cause  of  the 
feeling ;  in  other  words,  the  feeling  is  a  subjective  one.  Sub- 
jective feelings  are  either  pleasurable  or  painful,  while  the 
neutral  feelings  belong  to  the  objective  variety.  Pleasurable 
feelings  being  agreeable  we  desire  to  retain  them  as  long  as 
possible  in  consciousness,  while  painful  feelings  being  repugnant 
we  desire  to  exclude  them  as  soon  as  possible  from  conscious- 
ness. And  the  desire  to  retain  the  pleasurable  and  to  avoid  the 
painful  feelings  leads  by  various  degrees  of  composition  to  the 
complex  emotions.  This  is  not  the  place  to  advance  a  theory 
of  pleasures  and  pains  ;  but  it  may  be  remarked  that  an  agree- 
able feeling  is  caused  by  a  moderate  exercise  of  the  sensory 
mechanism,  and  that  a  more  or  less  diffused  liberation  of  energy, 
throughout  a  large  portion  of  the  nervous  system,  is  the  physical 
condition  of  intense  pleasure.  When  a  considerable  portion  of 
the  sensory  mechanism  is  not  duly  exercised,  a  feeling  of  dis- 


GENERAL  SYMPTOMATOLOGY.  83 

comfort  is  occasioned ;  and  when  there  is  a  large  liberation  of 
energy  in  a  limited  portion  of  the  sensory  apparatus,  in  a  short 
time,  acute  pain  is  caused.  A  medium  degree  of  the  normal 
stimulus  of  a  peripheral  end  organ  is  pleasurable,  while  an 
excess  of  the  same  stimulus  is  painful.  A  strong  light  or  a  loud 
noise  causes  a  painful  feeling ;  but  the  feeling  caused  by  excess 
of  stimulus  to  the  end  organs  of  the  cutaneous  sensory  nerves, 
or  to  the  afferent  nerves  themselves,  is  the  type  to  which  we 
usually  refer  our  elementary  painful  feeliogs. 

(II.)  The  Special  or  Objective  Feelings. — When  the  point  of 
one  of  our  fingers  experiences  some  resistance  we  conclude  that 
the  finger  has  come  in  contact  with  something  hard.  In  this 
case  we  have  not  simply  localised  the  feeling  in  the  finger,  but 
we  have  come  to  regard  it  as  a  quality  inherent  in  some  external 
object,  and  consequently  the  feeling  may  justly  be  named 
objective.  We  have  seen  that  the  most  prominent  accom- 
paniment of  the  subjective  feelings  is  a  desire  to  retain  the 
pleasurable  feelings  in,  and  to  exclude  the  painful  feelings  from, 
consciousness;  but  the  most  prominent  accompaniment  of  the 
objective  feelings  is  a  belief  in  the  existence  of  an  external 
cause  of  the  feeling;  and  consequently  the  latter  kind  of  feelings 
may  also  be  called  cognitions.  In  sensation,  or  the  first  degree 
of  objective  feeling,  the  mind  is  occupied  in  localising  the  feeling 
in  the  organism,  as  when  a  person  says  he  feels  something  hard 
with  his  finger ;  the  present  consciousness  corresponds  to  the 
impression  made  upon  the  finger,  and  consequently  a  sensation 
may  be  termed  a  presentative  cognition.^  But  if,  while  re- 
sistance to  the  finger  is  the  only  feeling  presented  in  conscious- 
ness, the  subject  judges  that  this  resistance  is  caused  by  an 
external  object  such  as  a  table,  and  thus  forms  a  perception 
of  the  object,  it  is  obvious  that  the  cognition  is  in  great  part 
made  up  of  feelings  which  are  only  revivications  of  previously 
experienced  feelings,  or,  in  other  words,  which  are  only  repre- 
sented in  consciousness.  A  perception  is,  therefore,  composed 
of  a  few  presented  feelings  and  a  large  number  of  represented 
feelings,  and  may  in  Mr.  Herbert  Spencer's  language  be  called  a 
presentative  representative  cognition.  We  thus  see  how  from 
the  simple  and  elementary  feelings  or  sensations  we  ascend  by 

>  Spencer  (Mr.  H,).    Principles  of  Psychology.    VoL  II.,  1870,  p.  512  et  seq. 


84  GENERAL  SYMPTOMATOLOGY. 

gradually  increasing  degrees  of  combination  to  the  more  and 
more  complex  cognitions,  and  ultimately  to  the  highest  opera- 
tions of  the  intellect. 

§  39.  The  Sensory  Mechanisms — The  sensory  mechanism  con- 
sists of  (I.)  individual  sensory  mechanisms,  and  (11.)  of  a  collec- 
tive sensory  mechanism.  Each  individual  mechanism  consists  of 
(1)  a  peripheral  sense  organ  for  the  reception  of  external  impres- 
sions (peripheral  end  organ) ;  (2)  nerve  paths  for  the  centripetal 
conduction  of  these  impressions  (sensory  conducting  paths);  and 
(3)  a  central  sense  organ  for  the  reception  of  the  conducted 
impressions  (cortical  sensory  centre).  The  collective  sensory 
mechanism  comprises  all  the  individual  sensory  mechanisms  and, 
in  addition,  a  highest  centre — the  sensorium  commune — by 
which  all  these  are  co-ordinated. 

(I.)  Individual  Sensory  Mechanisms. — When  an  impression 
is  made  upon  a  peripheral  end  organ  the  impulses  are  conveyed 
by  the  conducting  paths  to  the  sensory  centre  in  the  cortex 
of  the  brain,  and  a  molecular  movement  of  this  centre  is  the 
correlative  of  a  feeling  or  sensation.  In  the  case  of  the  sense  of 
muscular  effort,  however,  there  are  good  grounds  for  believing 
that  the  correlative  of  the  feeling  is  an  outward  and  not  an 
inward  discharge.  With  regard  to  this  subject  Prof.  Bain  says  : 
"It  does  not  follow  that  the  characteristic  feeling  of  exerted 
force  should  arise  by  an  inward  transmission  through  the  sensi- 
tive filaments ;  on  the  contrary,  we  are  bound  to  presume  that 
this  is  the  concomitant  of  the  outgoing  current  by  which  the 
muscles  are  stimulated  to  act."^  A  similar  view  has  recently 
been  advocated  by  Strieker.^  But  whether  the  sensation  is  asso- 
ciated with  the  cortical  motor  disturbance  set  up  by  the  ingoing 
currents,  or  with  that  which  initiates  the  outgoing  currents,  it  is 
evident  that  there  must  be  some  kind  of  quantitative  relation- 
ship existing  between  the  amount  of  molecular  disturbance 
generated  and  the  degree  of  the  resulting  sensation.  The 
amount  of  molecular  disturbance  produced  in  a  sensory  centre 
must  depend  upon  the  strength  of  the  stimulus  applied  to  the 

1  The  Senses  and  Intellect.    By  Alexander  Bain,  LL.D.    Third  edition,  1868, 

P-  77. 

^  Studien  iiber  die  Bewegungs-vorstellungen,  von  Dr.  S.  Strieker.    Wien,  1882. 


GENERAL   SYMPTOMATOLOGY.  85' 

periphery,  and  the  degree  of  irritability  and  consequent  specific 
resistance  of  the  sensory  mechanism.  The  intensity  of  the  sensa- 
tion, therefore,  must  vary  directly  according  to  (1)  the  strength 
of  the  stimulus  applied  and  (2)  the  degree  of  irritability  of  the 
sensory  mechanism ;  while  it  is  of  importance  also  to  note  (3) 
the  time  which  elapses  between  the  application  of  a  stimulus  to 
the  surface  of  the  body  and  the  resulting  sensation,  inasmuch  as 
the  period  of  sensory  conduction  may  be  either  retarded  or 
accelerated  in  disease. 

(1)  Relation  of  the  Intensity  of  the  Resulting  Sensation  to 
the  Strength  of  the  Stimulus. — The  degree  of  the  irritability  of 
the  sensory  mechanism  may,  for  practical  purposes,  be  regarded 
as  constant  in  health,  and  the  intensity  of  the  sensation  then 
varies  only  according  to  the  strength  of  the  applied  stimulus. 
The  relation  between  the  strength  of  the  stimulus  and  the 
intensity  of  the  resulting  sensation  is  not,  however,  a  simple 
one,  even  under  healthy  conditions. 

A  candle  lighted  in  a  dark  room  gives  us  a  luminous  sensation 
of  a  certain  intensity ;  but  a  second  lighted  candle,  although  it 
increases,  yet  does  not  double  the  intensity  of  the  sensation,  and 
a  third  candle  produces  still  less  effect.  The  true  relation 
between  the  degree  of  stimulus  and  the  intensity  of  the  sensa- 
tion was  first  discovered  by  determining  what  increase,  of  a 
stimulus  already  in  action,  causes  the  smallest  possible  increase 
of  sensation.  Weber  was  the  first  to  formulate  the  law  of  rela- 
tion between  the  stimulus  and  the  resulting  sensation.  Weber's 
law  is :  that  the  increase  of  stimulus  necessary  to  produce  the 
smallest  possible  increase  of  sensation  is,  within  certain  limits, 
directly  proportional  to  the  strength  of  stimulus  already  applied. 
This  law,  which  is  applicable  to  all  the  organs  of  sense,  has 
received  a  more  definite  enunciation  from  Fechner,  Regarding 
sensation  as  the  sum  of  a  series  of  increments  of  sensation, 
corresponding  to  increments  of  stimulus,  Fechner  adopted  the 
mathematical  operation  of  integration,  and  concluded  that 
sensations  increase,  not  in  proportion  to  the  strength  of 
the  stimulus,  but  to  the  logarithm  of  the  strength  of  the 
stimulus. 

(2)  Relation  of  the  Intensity  of  the  Resulting  Sensation  to 
the  Degree  of  Irritability  of  the  Sensory  Mechanism. — The 


86  GENERAL   SYMPTOMATOLOGY. 

intensity  of  a  sensation  varies  in  disease,  not  only  according  to 
the  strength  of  the  external  stimulus  applied,  but  also  according 
to  the  degree  of  the  irritability  of  the  sensory  mechanism  itself. 
When  the  irritability  of  the  cells  and  fibres  which  constitute 
the  sensory  mechanism  is  in  any  way  altered,  there  is  a  corre- 
sponding change  in  the  intensity  of  the  sensation  caused  by  an 
applied  stimulus,  the  healthy  reaction  being,  of  course,  regarded 
as  the  standard  of  comparison. 

(a)  Hypercesthesia. — If  the  irritability  of  the  cells  and  fibres 
which  constitute  the  sensory  mechanism  is  increased,  the  in- 
tensity of  the  sensation  resulting  from  an  applied  stimulus  is 
also  increased  in  a  corresponding  degree.  When  a  stimulus, 
such  as  a  touch  on  the  skin,  which  in  health  gives  rise  to  a 
very  slight  degree  of  an  intellectual  sensation,  either  causes  an 
undue  amount  of  the  same,  or,  what  is  more  usual,  induces  a 
painful  feeling,  the  condition  is  called  Hypercesthesia. 

(h)  Hyperalgesia. — When  a  stimulus,  such  as  the  prick  of  a 
pin,  which  in  health  causes  a  slight  degree  of  a  painful  feeling, 
causes  an  undue  amount  of  the  same  feeling,  the  condition  is 
called  Hyperalgesia  or  Hyperalgia. 

(c)  Ancesthesia. — When  the  irritability  of  the  cells  and  fibres 
constituting  the  sensory  mechanism  is  diminished  or  abolished, 
the  sensation  resulting  from  a  particular  stimulus  becomes  also 
diminished  or  abolished.  When  the  intellectual  sensations  are 
diminished  or  abolished,  the  condition  is  called  Anaesthesia. 
The  term  Hypcesthesia  has  been  introduced  by  Eulenburg  to 
indicate  diminution  of  sensory  reaction,  while  he  limits  the 
meaning  of  ancesthesia  to  its  abolition.  But,  in  order  not  to 
multiply  words,  the  latter  term  will  be  used  in  the  subsequent 
pages  in  a  general  sense  as  iacluding  both  conditions. 

(d)  Analgesia. — When  the  painful  feelings  induced  by  the 
application  of  stimuli  are  diminished  or  abolished,  the  condition 
is  called  Analgesia  or  Analgia.  Eulenburg  has  proposed  the 
term  hypalgesia  or  hypalgia,  to  indicate  diminution  of  painful 
reaction,  while  limiting  analgesia  to  its  abolition.  We  prefer 
to  dispense  with  this  refinement. 

(e)  Neuralgia. — Pain  is  often  a  symptom  of  disease  in  the 
absence  of  all  external  stimulation.  Severe  pain  accompanies 
local  inflammation  and   other  diseases,    but   at   times   severe 


GENERAL   SYMPTOMATOLOGY.  87 

paroxysms  of  pain,  limited  to  the  course  of  a  sensory  nerve,  is 
the  prominent  symptom  of  the  disease,  and  when  this  is  the  case 
the  condition  is  called  Neuralgia. 

(/)  Parcesihesia. — Various  other  elementary  disorders  of  sen- 
sation are  experienced,  independently  of  any  external  impres- 
sions, but  which  cannot  be  included  under  any  of  the  previous 
categories,  and  are  therefore  grouped  under  the  general  term 
parcesihesia.  The  cutaneous  pariesthesise  are  such  sensations  as 
pruritus,  tickling,  numbness,  furriness,  crawling,  feelings  of  heat 
and  cold.  The  visceral  parassthesise,  which  form  a  very  important 
group  of  symptoms,  are  such  feelings  as  hunger,  thirst,  nausea, 
disgust,  the  feelings  of  suffocation  and  fainting,  and  other  organic 
sensations.  In  so  far  as  these  feelings  are  painful  they  may  be 
called  Paralgesia^. 

(g)  Pseudo-^sthesioi. — Different  sensations  and  perceptions 
may  be  experienced  in  the  absence  either  of  corresponding  im- 
pressions and  objects,  or  of  any  irritation  of  the  peripheral  end 
organs  or  of  the  conducting  paths. 

Illusions. — In  illusions  an  erroneous  perception  of  external 
objects  and  relations  is  formed.  The  presentative  constituents 
of  the  perception  as  rendered  in  consciousness  are  true,  but  the 
representative  constituents  are  erroneous.  Thus  when  a  person 
sees  a  mirage  the  oculo-muscular  impressions  of  the  visual 
apparatus  are  correctly  rendered  in  consciousness,  but  the  belief 
that  the  representative  feelings,  such  as  the  tactual,  gustatory, 
and  other  sensations  which  concur  to  make  up  our  experience  of 
a  large  sheet  of  water,  would  be  experienced  by  walking  over 
a  certain  distance  of  ground  would  be  found  to  be  erroneous. 
When  the  presented  constituents  of  a  perception  have  a  strong 
tendency  to  call  up  in  consciousness  a  combination  of  represented 
constituents  which  do  not  correspond  to  the  reality,  this  is  an 
illusion,  even  although  the  experience  of  the  subject  may  enable 
him  to  counteract  the  tendency  to  believe  in  the  reality  of  the 
perceived  object.  A  mirage,  for  instance,  is  an  illusion  even  if 
the  experience  of  an  instructed  traveller  enables  him  not  to 
believe  or  act  upon  the  suggested  perception  of  a  lake. 

Hallucinations. — A  sensation  in  the  absence  of  any  external 
cause,  or  of  local  irritation  of  the  peripheral  end  organs,  or  of 
the  sensory  conducting  paths,  is  a  hallucination.     It  would 


88  GENERAL   SYMPTOMATOLOGY. 

appear  that  the  sensory  cortical  centre  enters  into  spontaneous 
activity  in  the  absence  of  any  external  impression. 

Delusions. — A  delusion  does  not  necessarily  imply  a  disorder 
of  the  elementary  sensory  apparatus.  The  subject  of  delusions 
may  perceive  objects  and  events  as  they  really  exist,  but  he 
forms  a  distorted  conception  of  the  properties  and  relations  of 
things,  which  leads  him  to  form  false  conclusions  with  regard  to 
them.  In  the  aggravated  delusions  of  the  insane  the  subject 
doubtless  accepts  his  illusions  and  hallucinations  as  realities,  and 
be  is  thus  led  to  inferences  which  are  greatly  at  variance  with 
the  common  sense  of  mankind. 

(3)  Retardation  and  Acceleration  of  Sensory  Conduction. — 
The  interval  which  elapses  between  the  instant  at  which  a 
stimulus  is  applied  to  a  sensory  surface  and  the  moment  at 
which  the  subject  makes  a  voluntary  signal  to  indicate  that  the 
sensation  has  been  perceived,  has  been  called  by  Exner  "the 
reaction  period."  The  normal  "reaction  period"  may  be  either 
increased  or  diminished.  The  conduction  of  centripetal  impres- 
sions is  accelerated  in  cases  of  hypersesthesia,  and  retarded  in 
cases  of  ansesthesia;  hence  the  length  of  the  reaction  period 
is  diminished  in  the  former,  and  increased  in  the  latter. 
Retardation  of  conduction,  however,  is  a  much  more  important 
and  reliable  evidence  of  disease  than  acceleration,  inasmuch  as 
the  former  is  much  more  easily  estimated  than  the  latter.  The 
normal  reaction  period  is  indeed  so  short  that  acceleration  of 
conduction  can  only  be  detected  by  the  aid  of  refined  physio- 
logical apparatus  ;  but  retardation  of  it,  on  the  other  hand, 
may  occur  to  such  an  extent  as  to  be  readily  appreciable  to  the 
unaided  senses,  and  the  symptom  thus  affords  a  valuable  aid  in 
diagnosis. 

(II.)  The  Collective  Sensory  Mechanism:  Sensorium  Com- 
mune.— In  so  far  as  the  collective  sensory  mechanism  consists 
of  the  individual  mechanisms  it  does  not  require  further  notice, 
but  the  disturbances  of  the  elementary  functions  of  the  highest 
sentient  centre  remain  to  be  considered.  It  is,  of  course,  impos- 
sible to  deal  with  the  disturbances  of  the  highest  co-ordinating 
sensory  centre  without  at  the  same  time  making  a  tacit 
reference  to  the  individual  cortical  sensory  centres. 

(1)  Consciousness. — The  consciousness  of  a  person  at  a  par- 


GENERAL   SYMPTOMATOLOGY.  89 

iScular  time  consists  of  the  aggregate  of  his  feelings,  cognitions, 
and  volitions,  together  with  a  memory  of  the  past  and  an  ex- 
pectation of  the  future.  Molecular  activity  of  the  cells  and 
fibres  of  the  sensorium  commune,  including  the  individual  sen- 
sory centres,  is  the  correlative  of  all  conscious  states ;  when  the 
highest  centre  is  active  the  consciousness  of  the  individual  in 
some  of  its  forms  is  lively,  when  the  centre  is  comparatively 
inactive  consciousness  is  blunted,  and  when  the  molecular 
activity  of  the  centre  ceases  consciousness  is  abolished. 

(2)  Unconsciousness. — The  molecular  activity  of  the  sensorium 
commune  is  intermittent,  and  under  normal  conditions  it  is  sus- 
pended for  several  hours  every  night,  and  during  this  time  con- 
sciousness is  abolished.  This  constitutes  sleep.  If  the  subject 
cannot  be  aroused  from  this  condition  by  the  application  of 
ordinary  stimuli  to  the  surface  of  the  body  the  condition  is  called 
somnolence,  or  sopor,  and  if  the  unconsciousness  becomes  so 
profound  that  the  subject  cannot  be  aroused  by  the  strongest 
external  stimuli  the  condition  is  called  coma.  Other  unconscious 
conditions,  such  as  somnambulism  and  the  mesmeric  state,  will 
be  subsequently  described. 

(3)  Semi- Consciousness  or  Sub-Consciousness. — Between  the 
active  consciousness  of  a  healthy  person,  after  being  restored  by 
sleep,  and  complete  insensibility  there  are  all  degrees  of  diminu- 
tion of  consciousness.  It  is  well  known  that  when  the  attention 
of  a  person  is  strongly  directed  to  one  particular  subject  he 
becomes  insensible  to  ordinary  impressions  upon  his  sensory 
organs.  A  still  profounder  degree  of  diminution  of  the  activity 
of  consciousness  is  manifested  by  persons  after  suffering  great 
fatigue  and  loss  of  sleep.  Under  such  circumstances  a  person 
may  walk  about  in  a  half-conscious  state,  and  a  similar  dazed 
condition  is  frequently  observed  after  epileptic  seizures.  Such 
conditions  are  very  liable  to  be  associated  with  motor  distur- 
bances. When  the  inhibitory  action  of  the  highest  co-ordinating 
centre  is  removed,  the  functional  activity  of  the  lower  centres 
may  become  increased.  There  can  be  no  doubt  that  many 
atrocious  murders  are  committed  during  the  period  of  semi- 
consciousness which  may  follow  an  epileptic  seizure ;  and  it  is 
well  known  how  fierce  and  brutal  many  men  become  during  the 
semi-conscious  condition  induced  by  drunkenness.     In  delirium'. 


90  GENERAL  SYMPTOMATOLOGY. 

again,  the  highest  form  of  consciousness  is  in  abeyance,  while  the 
lower  forms  are  abnormally  active.  The  patient,  for  instance,  is 
unable  to  sleep,  and  yet  he  is  only  partially  conscious  of  sur- 
rounding objects  and  events  ;  he  is  subject  to  illusions,  hallu- 
cinations, and  delusions,  and  motor  disturbances  are  manifested 
by  great  restlessness  and  incoherent  speech.  It  is  probable  that 
in  delirium  the  stock  of  irritable  matter  in  the  grey  substance  of 
the  cortex  is  much  exhausted,  and  that  what  remains  manifests 
an  undue  degree  of  irritability,  so  that  the  protoplasm  gives  out 
energy  either  spontaneously  or  on  the  application  of  very  slight 
stimuli.  But,  although  the  patient  is  only  semi-conscious  in 
delirium,  yet  his  mental  experiences  during  that  time  may  be 
subsequently  remembered  with  painful  intensity.  This  also 
occurs  in  dreams.  The  patient  at  the  time  is  wholly  uncon- 
scious of  external  impressions,  but  a  portion  of  the  sensorium 
must  enter  into  spontaneous  activity,  and  the  subject  is 
partially  conscious  of  a  succession  of  feelings  and  images,  either 
of  a  joyful  or  of  a  painful  kind,  which  may  be  subsequently 
revived  in  memory  with  greater  vividness  than  almost  any  of  his 
mental  experiences  during  waking  hours.  Dreams  are  also 
frequently  accompanied  by  some  motor  disturbances,  such  as 
vocalisations  and  articulate  sounds.  The  images  of  dreams  are 
generally,  as  already  remarked,  either  joyful  or  painful,  and  it  is 
probable  that  the  great  emotional  disturbances  which  accompany 
the  mental  phenomena  of  dreams  and  delirium  will  account  for 
them  being  so  well  remembered  subsequently.  The  most 
prominent  feature  of  the  "  night  terrors  "  of  children  is  the  out- 
ward expression  of  extreme  terror  by  which  the  attack  is  mani- 
fested. The  partial  unconsciousness  which  precedes  or  follows 
an  epileptic  seizure  is  often  associated  with  the  outward  mani- 
festation of  one  of  the  emotions,  and  sometimes  by  a  corresponding 
inward  feeling.  The  aura  of  an  epileptic  attack  may  be  a  guilty 
expression ;  and  the  patient  may  subsequently  be  able  to  remem- 
ber that  immediately  before  the  attack  he  experienced  a  feeling 
as  if  he  had  been  guilty  of  some  infamous  action. 

What  appears  to  be  an  increase  of  consciousness  often  results 
from  a  diminished  activity  of  the  higher  sentient  centres.  In- 
crease of  the  normal  desires  and  appetites  sometimes  results 
from  a  peripheral  irritation,  but  a  person  is  liable  to  an  illegiti- 


GENERAL   SYMPTOMATOLOGY.  91 

mate  indulgence  of  the  passions  when  the  moral  feelings  are 
weakened,  and  temptation  is  apt  to  be  strongest  during  states  of 
mental  enfeeblement  from  cerebral  exhaustion.  It  is  then  also 
that  remorse  for  previous  indulgence  is  liable  to  become  quite 
disproportionate  in  its  intensity  to  the  degree  of  guilt,  and  may 
be  experienced  in  the  absence  of  any  guilt  to  atone  for.  The 
fact  that  a  desire  is  liable  to  become  predominant  during  states 
of  semi-consciousness  is  used  with  fine  effect  by  the  late  George 
Eliot  in  "Silas  Marner,"  when  Dunstan  Cass  is  about  to  steal  the 
hoard  of  guineas  collected  by  the  miserly  habits  of  the  poor  weaver. 
Dunstan,  on  reaching  the  cottage  in  the  temporary  absence  of 
its  owner,  hastily  concluded  that  Silas  was  dead.  The  author 
now  proceeds :  "  He  went  no  further  into  the  subtleties  of  evi- 
dence ;  the  pressing  question,  '  Where  is  the  money  ? '  now  took 
such  entire  possession  of  him  as  to  make  him  quite  forget  that 
the  weaver's  death  was  not  a  certainty.  A  dull  mind  once 
arriving  at  an  inference  that  flatters  a  desire  is  not  able  to  retain 
the  impression  that  the  notion  from  which  the  inference  started 
was  purely  problematical.  And  Dunstan's  mind  was  as  dull  as 
the  mind  of  a  felon  usually  is."^  The  depressing  emotions,  such 
as  fear  and  anger,  are  also  liable  to  become  excessive  during 
states  of  nervous  exhaustion  ;  it  is  a  matter  of  common  observa- 
tion that  a  person  who  is  in  feeble  health  is  often  very  irascible. 
Experiments  on  animals  have  shown  that  a  nerve  whose  nutri- 
tion is  lowered  discharges  its  energy  more  readily  than  one 
whose  nutrition  is  perfect,  and  similarly  when  the  nutrition  of 
the  sensorium  commune  is  defective  it  responds  to  stimuli  of 
less  intensity  than  when  its  nutrition  is  normal. 

(4)  Double  Consciousness  :  Periodio  Amnesia.  —  Closely 
allied  to  somnambulism  and  the  mesmeric  sleep  is  the  curious 
condition  which  has  been  called  double  consciousness,  or  periodic 
amnesia.  In  this  condition  the  subject  is  liable  to  periodic 
seizures,  which  may  last  from  some  hours  to  as  many  days,  and 
during  which  there  is  complete  forgetfulness  of  the  feelings 
and  events  of  ordinary  existence,  although  rational  thought  and 
action  still  remain.  As  M.  Taine^  expresses  it,  the  subject  "has 
two  memories,  the  first  only  recalling  events  of  the  first  state, 

» •'  Silas  Marner,"  by  George  Eliot,  p.  32. 
^ Taine.     De  lintelligeace,  T.  L,  p.  180. 


^^  GENERAL   SYMPTOMATOLOGY. 

and  the  second  only  events  of  the  second  state."  Cases  illus- 
trative of  this  condition  have  been  described  by  Macnish, 
Mesnet,  and  others,^ 

(5)  Abnormal  States  of  ConsGiousness.  — There  are  some 
abnormal  elementary  feelings  which  must  be  regarded  as  quali- 
tative rather  than  quantitative  alterations  of  consciousness.  As 
examples  of  these  may  be  mentioned  (a)  headache,  (b)  vertigo, 
and  (c)  fainting.  To  the  consideration  of  these  may  be  added  a 
few  remarks  on  (d)  abnormal  appetites  and  emotions. 

(a)  Headache. — Although  headache  is  an  excess  of  painful 
feeling,  yet  it  cannot  as  a  rule  be  regarded  as  an  excess  of  any 
normal  feeling,  or  of  any  feeling  which  can  be  excited  by  the 
application  of  external  stimuli.  From  this  statement  neuralgic, 
rheumatic,  and  probably  some  other  forms  of  headache  must  be 
excepted,  but  what  is  generally  known  as  a  nervous  headache 
is  a  truly  abnormal  feeling,  and  must  be  experienced  by  a  person 
before  he  can  form  an  adequate  idea  of  it.  Such  headaches  are 
caused  by  changes  of  the  circulation  in  the  brain,  the  circulation 
of  poisons  in  the  blood,  or  they  may  arise  spontaneously  at 
recurring  intervals.  It  is  probable  that  in  all  of  them  there  is 
an  alteration  of  the  irritability  of  the  cells  and  fibres  of  thei 
sensorium.  Recurring  headaches  are  generally  associated  with 
vaso-motor  phenomena  in  the  regions  of  distribution  of  the  cer- 
vical sympathetic  nerves,  but  it  is  probable  that  these  are 
the  results  and  not  the  cause  of  the  sensorial  disturbance.  Such 
headaches  are  regarded  by  Dr.  Hughlings  Jackson  as  a  sensory 
epilepsy  and  as  being  dependent  upon  a  discharge  from  the 
sensory  portion  of  the  cortex  of  the  brain. 

(6)  Vertigo  is  a  sensation  of  swimming  in  the  head,  during 
which  surrounding  objects  appear  to  oscillate  before  the  eyes,  or 
to  rotate  in  a  definite  direction,  and  which  is  also  accompanied 
by  a  sense  of  staggering  or  of  rotation  of  the  body.  Vertigo 
appears  to  be  the  subjective  correlation  of  want  of  co-ordination 
between  the  various  muscular  contractions  necessary  for  adjust- 
ing the  body  to  the  different  objects  which  surround  it  in  space. 
It  is  a  prominent  symptom  of  those  diseases  in  which  the  auto- 
matic mechanism  for  maintaining  the  erect  posture  is  deranged^, 
such  as  affections  of  the  cerebellum  and  M^nike's  disease.    The 

1  See  Du  Saulle  (Dr.  Legrand).    Les  Hyst^riques,  1882,  p.  266  et  seq. 


GENERAL  SYMPTOMATOLOGY.  93 

position  of  the  body  in  space  is  largely  determined  by  the  asso- 
ciation of  objects  seen  with  the  appreciation  of  the  position  of 
the  eyes  and  head.  Displacement  of  the  position  of  the  eyes, 
such  as  occurs  in  paralysis  of  one  or  more  of  the  recti  muscles, 
or  of  the  position  of  the  head,  such  as  occurs  in  rotation  of  the 
head  with  conjugate  deviation  of  the  eyes,  and  in  the  compulsory 
movements  to  be  subsequently  described,  is  also  accompanied 
by  severe  vertigo.  This  symptom  frequently  attends  visceral 
disease,  as  dyspepsia,  and  it  is  then  probably  caused  by  vaso-motor 
changes  influencing  the  cerebral  circulation.  This  opinion  is 
rendered  all  the  more  probable  from  the  fact  that  vertigo  is  a 
troublesome  symptom  both  of  an89mia  and  congestion  of  the 
brain.  Vertigo  is  usually  accompanied  by  motor  phenomena  in 
the  region  of  distribution  of  the  pneumogastric,  such  as  feeble 
and  irregular  pulse,  irregular  respiration,  and  vomiting. 

(c)  Fainting  is  a  deadly  feeling  caused  by  sudden  anaemia  of 
the  brain,  occasioned  by  severe  loss  of  blood,  or  cardiac  failure. 
It  also  is  attended  by  gasping  respiration,  and  frequently  accom- 
panied by  vomiting. 

(d)  A  bnormal Appetites, Emotions,and  Impulses. — Drunken- 
ness may  be  regarded  as  an  abnormal  appetite,  especially  when  it 
assumes  the  aggravated  formofdipsomania;  but  the  mostremark- 
able  example  of  an  abnormal  appetite  is  afforded  by  the  condition 
described  by  WestphaP  and  others  as  perverted  sexual  instinct 
(contrare  sexualempfindung).  This  condition  is  defined  b}'^  West- 
phal  as  "  a  congenital  perversion  of  the  sexual  instinct  with  re- 
tained consciousness  of  the  morbid  nature  of  the  condition,"  and 
the  recorded  cases  show  that  some  persons  are  attracted  in  their 
sexual  desires  exclusively  by  individuals  of  their  own  sex.  The 
abnormal  emotions  can  only  be  briefly  mentioned  here,  inas- 
much as  they  do  not  belong  to  the  elementary  feelings.  The 
most  remarkable  of  these  emotions  consist  of  a  morbid  dread 
experienced  in  the  absence  of  any  circumstance  or  event  which 
could  be  thought  in  the  remotest  degree  capable  of  inducing  such 
a  feeling.  Some  persons  experience  an  unconquerable  feeling  of 
dread  when  they  are  alone  in  an  open  space  (angoraphobia) ; 
others  have  the  same  feeling  when  in  a  narrow  lane  between  two 

'  Westphal  (C).  Arch,  fiir  Peychiatrie,  Bd.  II.,  1869,  a.  73.  See  also  "Per- 
verted  Sexual  Instincts,"  by  Dr.  Julius  Krueg.     Brain.    Vol.  IV.,  1881-2,  p.  368. 


94  GENERAL  SYMPTOMATOLOGY. 

walls  (claustrophobia).  Some  people  have  a  morbid  dread  of 
society  (anthrophohia),  while  there  are  some  men  who  only 
experience  an  aversion  to  the  society  of  women  (gynephobia). 
Some  persons  are  totally  unable  to  sign  their  names  in  the 
presence  of  a  witness.  A  gentleman  in  business  once  told  me 
that,  while  able  to  keep  accounts  and  attend  to  his  business  as 
well  as  ever,  he  found  himself  totally  unable  to  sign  a  cheque  if 
one  of  his  clerks  made  a  sudden  demand  for  one.  Suicidal, 
homicidal,  and  other  morbid  impulses  are  liable  to  become  uncon- 
trollable during  periods  of  great  nervous  exhaustion,  and  when 
the  highest  manifestations  of  consciousness  are  in  abeyance. 
Atrocious  crimes  are  usually  committed  by  persons  during  the 
period  of  depression  which  follows  a  prolonged  carouse,  or  when 
the  individual  is  in  a  state  of  semi -stupefaction,  either  from 
alcohol  or  as  a  sequel  to  an  epileptic  seizure. 

is  40.  Kinesioneuroses. — Muscular  contraction  is  caused  both 
in  health  and  disease  by  irritation  of  some  part  of  the  nervous 
system.  The  irritation  may  have  its  seat  in  the  intra-muscular 
nerve  endings — the  end  plates  of  the  striated  muscles,  or  the 
terminal  fibrils  of  the  unstriped  muscles ;  it  may  have  its  seat 
in  the. cells  of  the  peripheral  ganglia,  spinal  cord,  or  brain;  or 
the  contraction  may  occur  indirectly  from  irritation  of  the 
centripetal  nervous  apparatus. 

The  disorders  of  muscular  movements  admit  of  a  double 
classification — the  one  anatomical,  and  the  other  physiological — 
the  two  traversing  each  other  at  right  angles. 

(A)  Anatomical  Classification. — Motor  disturbances  may  be 
divided  into  those  which  affect  (I.)  the  muscles  of  external 
relation — external  kinesioneuroses;  (II.)  the  muscles  of  the 
internal  organs — visceral  kinesioneuroses;  and  (III.)  the  mus- 
cular fibres  of  the  vascular  system — vascular  kinesioneuroses, 
or  angioneuroses. 

(B)  Physiological  Classification. — Muscular  movements  may 
be  divided  according  to  the  functions  of  the  nervous  apparatus 
which  regulate  them  into  three  classes,  viz.,  (I.)  the  voluntary, 
(II.)  the  reflex,  and  (III.)  the  automatic. 

(I.)  Voluntary  Movements. — Voluntary  movements  are  caused 
by  stimulation  of  circumscribed  regions  of  the  cortex  of  the 


GENERAL  SYMPTOMATOLOGY.  95 

brain,  called  psycho-motor  centres,  the  impulses  being  conducted 
downwards  by  the  fibres  of  the  'pyramidal  tract  to  the  spinal 
cord,  and  through  the  motor  nerves  to  the  muscles. 

(II.)  Reflex  Movements. — Simple  reflex  movements  are  caused 
by  stimulation  of  afferent  fibres  or  of  their  peripheral  termina- 
tions, the  impulses  being  conveyed  either  to  peripheral  ganglia 
or  the  grey  substance  of  the  central  grey  tube,  and  reflected  by 
the  latter  through  the  efferent  fibres  to  the  muscles. 

(III.)  Automatic  Movements. — The  automatic  movements 
are  those  which  occur  spontaneously,  unconsciously,  and  in  the 
absence  of  external  irritation.  To  this  class  belong  the  contrac- 
tions concerned  in  maintaining  various  attitudes  in  space,  and 
which  are  probably  co-ordinated  in  the  cerebellum,  as  well  as 
movements  indicative  of  various  instincts,  probably  co-ordinated 
in  the  basal  ganglia.  But  although  the  definition  of  automatic 
movements  implies  the  absence  of  peripheral  stimulation  in  their 
genesis,  it  is  quite  certain  that  many  of  the  movements  usually 
regarded  as  automatic  are  induced  by  external  stimulation.  It 
is,  indeed,  exceedingly  difficult  to  say  when  a  reflex  movement 
ends  and  a  voluntary  or  an  automatic  movement  begins.  Prac- 
tically, however,  the  distinctions  between  these  three  classes  of 
movements  are  valid,  and  the  theoretical  difficulties  in  defining 
them  need  not  be  discussed  further  at  present. 

§  41.  The  Motor  Mechanisms. — The  motor  mechanism  consists 
of  a  regulative  and  an  executive  apparatus;  the  former  comprises 
(1)  nerve  centres  and  (2)  centrifugal  conducting  paths,  including 
the  nerves  and  nerve  terminations,  and  the  latter  consists  of  the 
muscles.  This  apparatus  may  therefore  be  called  the  neuro- 
muscular mechanism.  The  general  positions  of  the  chief  motor 
centres  and  conducting  paths  have  already  been  indicated.  In 
addition  to  the  cortical  motor  centres  for  the  regulation  of  the 
contractions  of  individual  portions  of  the  muscular  system,  it  is 
probable  that  we  must  assume  the  existence  of  a  higliest  motor 
centre  which  harmonises  all  the  movements  of  the  body — a 
motorium  commune,  corresponding  to  the  sensorium  commune 
of  the  sensory  mechanisms.  When,  for  instance,  I  move  my  hand 
to  grasp  an  object  while  in  the  erect  posture,  the  cortical  motor 
centre  of  the  hand  is  not  the  only  one  of  the  highest  centres 


96  GENERAL  SYMPTOMATOLOGY. 

which  must  be  called  into  activity.  The  movement  of  the  hand 
has  altered  the  position  of  the  centre  of  gravity  of  the  body,  and, 
slight  as  this  displacement  may  be,  it  must  necessitate  a  change 
in  the  degree  of  contraction  of  almost  every  one  of  the  muscles 
of  external  relation  all  over  the  body.  It  is,  therefore,  probable 
that  a  common  motor  centre  exists  in  the  cortex  of  the  brain, 
which  brings  into  unison  the  actions  of  all  the  individual  motor 
mechanisms.  It  is  not  necessary  to  believe  that  there  exists  a 
distinct  line  of  demarcation  between  the  highest  sensory  and  the 
highest  motor  centre.  It  is,  indeed,  likely  that  the  one  merges 
into  the  other,  as  do  the  afferent  and  efferent  portions  of  a  reflex 
arc  in  the  grey  matter  of  the  spinal  cord ;  or  it  might  be  more 
correct  to  say  that  the  two  centres  are  really  one,  which  forms 
the  highest  co-ordinating  centre  to  which  centripetal  conducting 
paths  convey  their  impulses,  and  from  which  issue  impulses  to  be 
transmitted  by  centrifugal  paths  to  the  muscles.  The  quantity 
of  motor  innervation  which  reaches  a  muscle  depends  upon  two 
factors,  (1)  the  primary  irritant  and  (2)  the  degree  of  irritability 
of  the  nervous  apparatus;  it  is  well  also  to  attend  (3)  to  the 
time  in  which  movements  are  executed,  inasmuch  as  acceleration 
and  retardation  of  motor  conduction  are  of  themselves  evidences 
of  disease. 

(1)  Relation  of  the  Intensity  of  the  Resulting  Contraction  to 
the  Strength  of  the  Stimulus.— The  degree  of  irritability  of  the 
various  parts  of  the  nervous  system  may  be  regarded  as  constant 
in  health,  and  the  intensity  of  the  muscular  contraction  as  varying 
only  in  proportion  to  the  strength  of  the  stimulus  which  has 
evoked  it.  The  proportion  between  the  degree  of  contraction 
and  the  strength  of  the  stimulus  is  not,  however,  a  simple  and 
direct  one,  inasmuch  as  a  certain  multiple  of  the  latter  is  not 
followed  by  a  corresponding  multiple  of  the  former.  No  accurate 
expression  of  the  relation  between  the  two  has  hitherto  been 
obtained  ;  all  that  we  are  warranted  in  saying  is  that  a  strong 
stimulus  is  followed  by  a  powerful  contraction,  and  conversely  a 
weak  stimulus  by  a  feeble  contraction.  It  may  be  remarked 
that  the  small  muscles  respond  to  feebler  stimuli  than  the  large 
muscles  of  the  body.  The  small  muscles  of  the  face,  eyes,  and 
larynx,  for  example,  respond  to  much  feebler  stimuli  than  do  the 
large  muscles  of  the  lower  extremities. 


GENERAL  SYMPTOMATOLOGY.  97 

(2)  Relation  of  the  Intensity  of  the  Resulting  Contraction  to 
the  Degree  of  Irritability  of  the  Nervous  Apparatus. — In  disease 
the  irritability  of  the  various  sections  of  the  nervous  system 
may  become  so  altered  that  no  assignable  proportion  exists  any 
longer  between  the  irritation  and  the  resulting  contraction. 
The  following  varieties  of  motor  disturbances  may  be  distin- 
guished : — 

{a)  HyperJdnesis. — When  a  stimulus  gives  rise  to  muscular 
contractions  which  are  in  excess  of  the  normal  proportion,  or 
when  an  undue  muscular  contraction  occurs  in  the  absence  of 
all  recognisable  external  stimulation,  the  condition  is  called 
hyperkinesis. 

(6)  Akinesis. — When  there  is  a  diminution  or  abolition  of 
the  power  of  exciting  the  muscles  to  contraction,  either  by 
voluntary,  reflex,  or  automatic  excitation,  the  condition  is  called 
akinesis.  The  term  hypokinesis  has  been  introduced  by 
Eulenburg  to  designate  the  diminution  of  motor  reaction  to 
excitation,  while  he  limits  akinesis  to  its  abolition;  but,  in 
order  not  to  multiply  words,  the  latter  term  is  used  here  in 
a  generic  sense  as  including  both  conditions. 

It  is  doubtful  whether  qualitative  changes  of  motor  activity 
are  ever  observed ;  hence  it  is  unnecessary  to  form  a  third  group 
of  motor  disturbances  termed  parakinesis,  corresponding  to  the 
sensory  affections  termed  pareesthesise. 

(c)  Synkinesis. — Although  motor  affections  do  not  present 
any  appreciable  qualitative  alterations,  yet  various  motor 
anomalies  are  frequently  observed  in  connection  with  paralysis 
or  spasm  of  some  of  the  muscles  of  groups  associated  in  their 
actions,  and  these  may  be  included  under  the  term  Synkinesis. 

(3)  Acceleration  and  Retardation  of  Motor  Conduction. — 
When  the  degree  of  irritability  of  the  nervous  system  is  very 
great,  motor  impulses  are  conducted  more  quickly  to  the  muscles 
than  under  normal  conditions.  But  acceleration  of  motor  im- 
pulses can  only  be  appreciated  by  the  aid  of  complicated 
mechanical  contrivances,  and  is  therefore  of  little  practical 
value  as  a  sign  of  disease.  Retardation  of  motor  conduction, 
however,  can  be  readily  appreciated  by  the  unaided  senses,  and 
is  therefore  a  valuable  diagnostic  sign.  Slowness  in  executing 
certaia  movements  is  a  sign  of  diminution  of  motor  power,  and 
VOL.  I.  H 


98  GENERAL  SYMPTOMATOLOGY. 

feebleness  of  the  muscles  of  the  hand,  for  instance,  may  some- 
times be  more  readily  detected  by  asking  the  patient  to  write 
his  name,  or  to  perform  "  the  devil's  tattoo"  on  the  table,  than 
by  estimating  the  strength  of  the  grasp. 

§  42.  Trophoneuroses. — Various  experimental  and  pathological 
facts  are  now  accumulated  which  show  that  a  nervous  apparatus 
exists  which  presides  directly  over  the  nutrition  of  the  tissues,  in 
addition  to  that  which  regulates  the  supply  of  blood  to  those 
parts.  It  is  the  nutritive  affections  that  result  from  direct  dis- 
turbances of  this  trophic  nervous  apparatus  which  alone  come 
under  our  consideration  at  present. 

The  trophoneuroses  admit  of  (A)  an  anatomical  and  (B)  a 
physiological  classification. 

(A)  Anatomical  Classification. — Trophoneuroses  may  be 
divided,  according  to  the  tissues  and  structures  affected,  into  (I.) 
nutritive  affections  of  the  nervous  system  itself ;  (II.)  those  of 
the  voluntary  muscles;  (III.)  those  of  the  skin  and  its  appen- 
dages; (IV.)  trophic  affections  of  the  joints  and  bones;  (V.) 
nutritive  and  secretory  disturbances  of  the  glandular  apparatus ; 
and  (VI.)  trophic  affections  of  the  internal  organs. 

(B)  Physiological  Classification. — The  trophoneuroses  may 
be  divided  from  the  physiological  standpoint  into  (I.)  trophic 
disorders  of  the  parenchymatous  organs,  as  manifested  by  an  in- 
crease or  diminution  in  the  volume  and  consistence  of  the  organ, 
and  (II.)  trophic  disorders  of  the  secretory  glands,  as  manifested 
by  quantitative  or  qualitative  changes  in  their  secretions.  The 
trophoneuroses  also  admit  of  a  physiological  division  into  (I.) 
reflex,  (II.)  automatic,  and  (III.)  psychical  trophoneuroses. 

(I.)  Reflex  Trophoneuroses. — It  is  very  probable  that  many 
acute  inflammations  of  internal  organs  are  caused  by  reflex 
irritation,  but  it  is  not  easy  to  adduce  an  illustration  which 
places  this  view  beyond  question.  But  the  powerful  influence 
which  reflex  irritation  exercises  over  secretion  is  readily  shown 
by  irritating  the  mucous  membrane  of  the  mouth  and  tongue, 
when  a  copious  flow  of  saliva  will  ensue. 

(II.)  Automatic  Trophoneuroses. — The  atrophy  which  volun- 
tary muscles  undergo  when  the  anterior  grey  horns  of  the  spinal 
cord  are  diseased  is  a  good  example  of  a  trophoneurosis  from 


GENERAL   SYMPTOMATOLOGY.  99 

interference  with  an  automatic  centre.  Although  the  reflex  arc 
is  also  interfered  with  in  such  cases  the  atrophy  is  not  likely  to 
be  caused  by  this. 

(III.)  Cerebral  or  Psychical  Trophoneuroses. — It  is  well  known 
that  mental  anxiety  and  worry  exercises  a  deleterious  effect  upon 
the  nutrition  of  the  whole  body,  and  that  the  hair  of  the  head 
may  turn  grey  in  a  single  night  under  circumstances  of  profound 
grief.  The  excessive  secretion  of  the  lachrymal  gland  during 
various  emotions  is  a  good  example  of  the  effects  which  the  brain 
may  exert  over  the  glandular  apparatus. 

§  43.  The  Trophic  Mechanisnn. — The  trophic  mechanism  con- 
sists, like  the  other  nervous  mechanisms,  of  conducting  paths  and 
centres,  but  the  exact  position  of  these  are  not  so  accurately 
ascertained  that  any  good  would  result  from  a  discussion  of  the 
subject  at  present. 

Disorder  of  the  trophic  mechanism  gives  rise  to  the  following 
nutritive  disorders  : — 

(1)  Neurotic  Hypertrophy. — In  hypertrophy  there  is  an  in- 
crease of  the  volume  of  the  elementary  parts  of  the  organ, 
while  its  form  and  structure  is  maintained. 

(2)  Neurotic  Atrophy. — In  atrophy  there  is  a  diminution  of 
the  volume  of  the  elementary  parts  of  an  organ,  but  its  form  and 
structure  is  also  retained.  Atrophy  may  sometimes  be  masked 
so  as  to  look  like  hypertrophy,  as  in  the  muscles  of  pseudo- 
hypertrophic paralysis. 

(3)  Neurotic  Paratrophies  and  Dystrophies. — Besides  abnor- 
mal increase  and  diminution  of  nutrition,  qualitative  alterations 
are  also  observed,  and  these  may  be  called  paratrophies  and 
dystrophies.  The  arthropathies  of  tabes  dorsalis,  and  the  circum- 
scribed erysipelas  and  glossy  fingers  which  occur  after  injury  to 
the  peripheral  nerves,  are  trophic  disturbances  which  cannot  be 
regarded  either  as  hypertrophies  or  atrophies. 

(4)  Quantitative  Changes  of  Secretion. — A  great  increase  or 
diminution  of  the  secretion  of  a  gland  may  be  taken  as  an 
indication  that  the  organ  is  in  a  state  of  nutritive  activity  or 
inactivity. 

(5)  Qualitative  Changes  of  Secretion. — In  addition  to  increase 
or  diminution  of  the  normal  secretion  of  a  gland,  it  may  also 


100  GENERAL   SYMPTOMATOLOGY. 

become  greatly  altered  in  quality  during  abnormal  conditions  of 
its  nervous  mechanism. 

Relation  between  the  Degree  of  Irritation  of  the  Trophic 
Mechanisms  and  the  Resulting  Nwtritive  Disorder. — Increase 
of  nervous  influence  will  produce,  as  might  be  expected,  hyper- 
trophy of  a  tissue.  The  great  increase  of  the  volume  of  muscles 
produced  by  healthy  exercise  may  be  taken  as  an  example  of 
this.  A  still  more  unexceptional  example  is  afforded  by  the 
hypertrophy  that  the  muscles  of  a  limb,  the  subject  of  post- 
hemiplegic chorea,  undergo.  These  muscles  are  often  subject  to 
severe  clonic  spasms,  and  although  the  influence  of  the  volun- 
tary nervous  apparatus  is  diminished,  there  can  be  little  doubt 
that  the  influence  of  some  of  the  inferior  centres  is  increased. 
But  hypertrophy  of  some  tissues  and  organs  sometimes  occurs 
from  a  diminution  of  nerve  influence,  Mantegazza^  observed 
hypertrophy  of  the  connective  tissue,  and  of  the  periosteum, 
bones,  and  lymphatic  glands  after  experimental  section  of  nerves 
in  animals.  And  division  of  the  large  trunks  of  the  extremities 
in  man  is  not  unfrequently  followed  by  circumscribed  hyper- 
plastic phenomena  in  certain  parts,  as  the  skin,  nails,  hairs, 
bones,  and  joints,  side  by  side  with  atrophy  of  other  parts,  as  the 
muscles  and  sub-cutaneous  tissue.  In  these  cases  it  is  im- 
possible to  exclude  the  action  of  prolonged  vaso-motor  changes. 
When,  for  instance,  the  sympathetic  nerve  is  divided  on  one  side 
of  the  neck  in  young  animals,  the  ear  on  that  side  attains  a 
larger  size  than  that  on  the  opposite  side.  The  temperature  of 
the  ear  on  the  side  operated  upon  is  higher  than  on  the  opposite 
side,  and  the  hair  of  the  enlarged  ear  is  longer  than  that  of  the 
other  ear  and  so  continues  for  several  months  together.^ 

Atrophy  is  caused  sometimes  by  a  diminution  of  the  normal 
innervation  of  the  part,  but  the  most  aggravated  forms  of 
muscular  atrophy,  for  instance,  appear  to  be  caused  by  irritative 
lesions  of  nerves.^    Neuralgia  again  is  frequently  associated  with 

1  Gaz.  med.  ital.  Lombard,  1867.  Abstr.,  Schmidt's  Jabrb.  Bd.  CXXX., 
p.  275. 

^  Bidder.  "On  Hypertrophy  of  the  Ear  after  Excision  of  a  Portion  of  the  Cervical 
Sympathetic  in  a  Babbit."  London  Medical  Becord,  June  24, 1874.  Vol.  XL,  p.  389. 
Also  Stirling.  "  Effect  of  Division  of  SjTnpathetic  Nerve  in  the  Neck  in  Young 
Animals  "    British  Medical  Journal,  August  28,  1875.     Vol.  II.,  p.  279. 

"  See  Charcot  on  Diseases  of  the  Nervous  System.  Translated  by  G.  Sigerson, 
M.D.    1878,  p.  28  et  seq. 


GENERAL   SYMPTOMATOLOGY.  101 

diminished  nutrition  of  the  parts  to  which  the  affected  nerve  is 
distributed.  In  trigeminal  neuralgia,  for  instance,  there  is 
frequent  loss  of  the  colour  of  the  hair  on  the  affected  side  of  the 
head,  or  of  the  eyelashes  and  eyebrows,  as  well  as  atrophy  of 
the  skin  and  of  the  remaining  soft  parts,  and  also  of  the  bones  of 
the  face.  But  neuralgia  is  caused  by  an  irritative  lesion  of  the 
sensory  nerves  or  of  some  parts  of  the  conducting  paths,  and  yet 
it  is  associated  with  a  diminution  of  the  nutrition  of  the  parts  to 
which  the  affected  nerve  is  supplied.  Qualitative  changes  of 
nutrition  also  appear  to  occur  sometimes  in  consequence  of 
irritative  nerve  lesions,  and  at  other  times  in  consequence  of 
paralysis.  Herpes,  for  instance,  is  often  associated  with  severe 
neuralgic  pains,  and  it  is  probably  caused  by  a  neuritis  of  the 
nerves  supplying  the  affected  parts.  Neuroparalytic  ophthalmia 
is  caused  by  irritative  lesions  of  trophic  fibres  which  descend 
from  the  Gasserian  ganglion,  or  which,  at  least,  are  found  in  the 
trunk  of  the  trigeminus.  Brown  S^quard  observed  a  bed-sore  to 
begin  on  the  sacrum  of  a  dog  seven  hours  after  he  had  produced 
an  inflammation  of  the  spinal  cord.  The  skin  on  that  place  was 
violet,  and  in  a  state  of  complete  gangrene  on  the  next  day.^  In 
this  case  also  the  nerve  lesion  was  probably  an  irritative  one,  but 
there  can  be  little  doubt  that  various  qualitative  nutritive  dis- 
turbances are  caused  by  the  diminution  or  abolition  of  the 
nervous  influence  of  a  part. 

The  influence  which  the  nervous  system  exerts  upon  the  secre- 
tion of  glands  is  much  better  ascertained  than  its  influence  upon 
the  nutrition  of  the  parenchymatous  organs.  Ludwig^  was  the 
first  to  show  that  faradic  stimulation  of  the  nerve  twigs,  from 
the  lingual  branch  of  the  fifth  nerve,  accompanying  Wharton's 
duct  to  the  submaxillary  gland,  caused  an  abundant  secretion  of 
watery  saliva,  relatively  rich  in  saline  and  poor  in  organic  con- 
stituents. He  also  showed  that  the  secretion  of  saliva  is  inde- 
pendent of  the  arterial  pressure,  since  irritation  of  the  nerves 
in  question  causes  the  manometric  pressure  to  be  greater  in 
Wharton's  duct  than  the  arterial  pressure  in  the  carotid.  He 
likewise  found  that  the  temperature  of  the  gland  rose  above  that 

1  British  Medical  Journal,  Vol.  IL,  1880,  p.  915. 

^  Ludwig.  Neue  Versuche  iiber  die  Beihilfe  der  nerven  zur  Speichelabson- 
derung.  Zeitschrift  fiir  nat.  Med.  Bd.  I.,  1851,  s.  255.  Lehrbuch  der  Physiologic. 
Bd.  IL,  p.  338. 


102  GENERAL  SYMPTOMATOLOGY. 

of  arterial  blood  during  the  stimulation.  But  Eckhard/  and 
subsequently  Bernard,^  proved  that  the  secretion  of  the  sub- 
maxillary gland  is  also  under  the  control  of  the  sympathetic 
nerves  distributed  to  the  gland  ;  and  that  stimulation  of  these 
nerves  causes  a  very  scanty  flow  of  viscid  saliva,  relatively  rich 
in  organic  and  poor  in  saline  constituents.  Bernard  also  showed 
that  stimulation  of  the  nerves  of  the  submaxillary  gland  caused 
changes  in  the  circulation  of  blood  through  the  gland.  He 
found  that  the  chorda  tympani  contained  vaso- dilator  fibres, 
and  that  stimulation  *of  the  fibres  produced  a  great  dilatation  of 
the  arteries  of  the  gland,  and  the  blood  passing  through  it  was 
not  only  largely  increased,  but  presented  a  florid  arterial  hue  in 
the  veins.  The  sympathetic  he  found  to  contain  vaso-con- 
strictor  fibres,  and  stimulation  of  these  caused  the  arteries  to 
contract,  and  thus  the  flow  of  blood  through  the  gland  was 
greatly  diminished,  and  it  presented  an  intensely  venous  hue  in 
the  veins.  It  was,  therefore,  supposed  that  variations  in  the 
quantity  and  quality  of  the  secretion  might  be  dependent  upon 
variations  in  the  circulation  of  blood  through  the  gland.  This 
view  was  to  a  large  extent  discredited  by  Ludwig's  experiments ; 
and  it  was  still  further  disproved  by  an  observation  made  by 
Keuchel,  and  subsequently  confirmed  by  Heidenhain.^  These 
observers  found  that  atropia  paralyses  the  secreting  fibres  of  the 
chorda  tympani,  while  leaving  the  circulation  of  the  submaxil- 
lary gland  unaffected,  so  that  stimulation  of  the  nerves  produces 
dilatation  of  the  vessels,  as  under  normal  circumstances.  It  is 
clear,  therefore,  that  the  increased  secretion  of  the  submaxillary 
gland,  caused  by  stimulation  of  the  chorda  tympani,  does  not 
depend  upon  stimulation  of  the  vaso -motor  fibres.  With 
respect  to  the  action  of  the  sympathetic  nerve,  it  was  proved 
by  von  Wittich*  that  stimulation  of  it  was  followed  by  the  usual 
changes  in  the  secretion  even  after  the  gland  was  rendered 
anaemic  by  the  carotid  having  been  previously  tied.  But 
although  these  experiments  undoubtedly  prove  that  the  secre- 

1  Eckhard.    Beitrage  zur  Anat.  u.  Phys.    Bd.  II.,  s.  81,  205.    Bd.  IIL,  s.  41. 

■^  Bernard  (C).  Comptes  Rendu.  1858.  Tome  XLVIL,  pp.  245,  373,  and 
Tome  LV.,  p.  341. 

3  Heidenhain.    Pfliiger's  Archiv.     Bd.  VL,  p.  309. 

*  Wittich  (von).  Virchow's  Archiv.  Bd.  XXXVII.,  s.  93,  and  Bd.  XXXIX., 
s.  184. 


GENERAL   SYMPTOMATOLOGY.  103 

tion  of  saliva  is  uader  the  coatrol  of  the  nervous  system,  yet  it 
must  not  be  supposed  that  the  secretion  of  the  gland  ceases 
when  the  nervous  influence  over  it  is  abolished.  Bernard  found 
that  division  of  all  the  nerves  supplying  the  salivary  glands  was 
followed,  after  a  temporary  cessation  of  secretion,  by  an  abun- 
dant flow  of  very  watery  saliva,  or  what  is  now  called  paralytic 
secretion.-^ 

It  will  thus  be  seen  that  the  relation  between  the  trophic 
nerves  and  the  parts  supplied  by  them  is  a  very  complicated 
one.  It  might  be  expected  that  irritation  of  trophic  fibres  would 
be  followed  by  hypertrophy  of  parenchymatous  organs  and  in- 
crease of  the  secretion  of  glands,  and  that  diminution  of  the 
trophic  influences  would  be  followed  by  atrophy  of  the  former 
and  diminished  secretion  of  the  latter.  But  the  actual  relation- 
ship between  the  amount  of  irritation  of  the  trophic  mechanism 
and  the  resulting  alteration  of  nutrition  and  secretion  is,  as 
already  remarked,  much  more  complex.  In  order  to  meet  this 
difficulty  it  has  been  supposed  that  there  are  two  kinds  of 
trophic  and  secretory  nerves,  the  one  acting  as  accelerators  and 
the  other  as  regulators  of  nutrition,  corresponding  to  the  accele- 
ratory  and  inhibitory  nerves  of  the  heart.  In  order  to  explain 
the  effects  on  the  chemical  constitution  of  the  saliva  produced 
by  irritation  of  fibres  of  the  cranial  and  sympathetic  nerves 
respectively,  Heidenhain^  assumes  that  both  nerves  contain 
secretory  and  trophic  fibres  but  in  unequal  proportions.  The 
cranial  nerves  according  to  this  supposition  contain  a  large  pro- 
portion of  secretory  fibres,  hence  irritation  of  them  produces  a 
copious  flow  of  watery  saliva ;  while  the  sympathetic  nerves 
contain  a  large  proportion  of  trophic  fibres,  and  irritation  of 
them  produces  a  scanty  flow  of  tenacious  saliva  rich  in  organic 
constituents.  It  is  right  to  add  that  some  pathologists  deny  the 
existence  of  trophic  nerves  for  the  parenchymatous  tissues,  and 
they  regard  the  nutritive  changes  which  undoubtedly  arise  after 
injuries  of  the  nervous  system  as  being  due  to  sensory  disorders 
and  vaso- motor  changes  in  association  with  other  deleterious 
influences.^     It  is  scarcely  necessary  to  say  that  Heidenhain's 

>  See  Gam^ee  (Prof.  A.).     Nature,  August  24,  1882,  p.  412. 

*  Hermann's  Handbach  der  Physiologie.    Bd.  V.,  Ab.  1,  s.  55. 

'  Hutchinson  (Mr.  J.).     British  Medical  Journal,  Vol.  II.,  1880,  p.  915, 


104  GENERAL  SYMPTOMATOLOGY. 

supposition  with  regard  to  the  existence  of  secretory  and  trophic 
fibres  in  the  nervous  apparatus  of  the  salivary  glands  is  also 
very  problematical.  The  whole  theory  of  trophic  nerves  is  at 
present  in  such  an  unsatisfactory  condition  that  little  good 
would  result  from  a  further  discussion  of  the  subject. 

§  44.  General  Classification. 

Elementary  nervous  symptoms  may  be  classified  according 
to  the  tissues  and  organs  affected.  The  anatomical  sub-division 
is  traversed  at  right  angles  by  the  physiological  divisions  pre- 
viously described,  and  both  may  be  combined  in  the  following 
scheme : — 

I. — jEsthesioneuroses. 

(A)  Anatomical  Classification. — 

(i.)  Sensory  affections  of  the  skin,  including  the  external  and 

exposed  portions  of  the  mucous  membranes, 
(ll.)  Sensory  affections  of  the  voluntary  muscles. 
(hi.)  Sensory  affections  of  the  passive  parts  of  the  locomotive 

apparatus  as  the  bones  and  joints. 
(iv.)  Sensory  affections  of  the  internal  parenchymatous  organs, 
(v.)  Sensory  disturbances  of  the  special  senses. 

These  groups  may  be  briefly  characterised  as  cutaneous, 
muscular,  articular,  visceral,  and  sensory  -^sthesioneuroses. 

(B)  Physiological  Classification. — 

(i.)  The  common  or  subjective  feelings, 
(ii.)  The  special  or  objective  feelings. 

II. — Kinesioneuroses. 

(A)  Anatomical  Classification. — 

(l)  Motor  affections  of  the  muscles  of  external  relation  or  of 

the  striped  muscles,  or  external  Jcinesioneuroses. 
(il.)  Motor    affections    of    the    internal    organs    or    visceral 

kinesioneuroses. 
(hi.)  Yaso -motor  disturbances — vascular  kinesioneuroses,  or 
angioneuroses. 


GENERAL  SYMPTOMATOLOGY.  105 

(B)  Physiological  Classification. — 

(l)  Reflex  kinesioneuroses. 
(li.)  Automatic  kinesioneuroses. 
(in.)  Voluntary  kinesioneuroses. 

III. — Trophoneuroses. 

(A)  Anatomical  Classification. — 

(l)  Trophic  affections  of  the  nervous  system  itself. 

(iLj  Trophic  changes  of  the  voluntary  muscles. 
(in.)  Trophic  affections  of  the  skin  and  epidermoidal  structures, 
(iv.)  Trophic  affections  of  the  joints  and  bones. 

(v.)  Nutritive  and  secretory  disturbances  of  the  glandular 

apparatus, 
(vi)  Trophic  affections  of  the  internal  organs. 

(B)  Physiological  Classification. — 

(l)  Reflex  trophoneuroses, 
(ii.)  Automatic  trophoneuroses, 
(in.)  Psychical  trophoneuroses. 


106 


CHAPTER    IV. 


I.— ELEMENTARY    AFFECTIONS    OF    INDIVIDUAL    SENSORY 
MECHANISMS. 

(I.)-SENSORY   DISTURBANCES  OF   THE   SKIN  (CUTANEOUS 
^STHESIONEUROSES). 

§  45.  General  and  Special  Cutaneous  Sensations. — The  sen- 
sations which  are  communicated  through  the  skin  may  be 
divided  into  general  or  common  sensations  and  special  or 
tactile  sensations;  and  each  of  these  groups  may  be  divided 
into  several  varieties.  The  first  group  consists  of  such  sensations 
as  pain,  itching,  titillation,  sensual  pleasure,  and  that  resulting 
from  electrical  excitation.  The  second  group  consists  of  the 
specific  sensations  of  pressure  and  temperature,  which  arise  in 
response  to  mechanical  and  thermal  stimuli.  Recent  observa- 
tions appear  to  show  that  painful  irritations  of  the  skin  are  due 
not  to  excessive  irritation  of  the  ordinary  nerve  terminations, 
but  to  irritation  of  special  end-organs. 

§  46.  Tactile  and  Pathic  Channels. — There  seem  to  be  dif- 
ferent channels  of  conduction  in  the  spinal  cord  and  brain  for 
tactile  and  painful  sensatioDS,  called  respectively  tactile  and 
pathic  channels.  It  does  not  appear  improbable  therefore  that 
these  channels  are  connected  with  different  peripheral  terminal 
organs.  In  disease  one  or  more  of  these  channels  may  be 
disturbed  while  the  others  remain  unaffected  ;  so  that  patho- 
logical conditions  may  be  said  to  analyse  the  various  sensations 
into  their  elementary  forms.  In  certain  diseases  of  the  brain  or 
of  the  spinal  cord  hypersesthesia  as  regards  temperature  has 
been  observed  while  sensitiveness  to  pressure  was  unaffected ; 
and,  conversely,  cases  have  been  described  where  the  patient 
could  tell  when  he  was  touched,  but  could  not  distinguish  be- 
tween hot  and  cold  bodies.  An  analogous  analysis  of  the  sensa- 
tions of  temperature  and  of  pain  may  be  effected  by  a  simple 


AFFECTIONS  OF  INDIVIDUAL  SENSORY  MECHANISMS.        107 


experiment.  If  the  elbow  is  dipped  into  a  very  cold  fluid,  the 
cold  is  only  felt  at  the  immersed  part  of  the  body ;  while  pain  is 
felt  in  the  finger  points  supplied  by  the  ulnar  nerve. 

§  47.  Methods  of  Examining  the  Sensory  Apparatus. 

Inasmuch  as  sensory  affections  can  only  be  known  through  the  state- 
ments and  gestures  of  the  patient  it  is  necessary  to  proceed  systematically 
with  our  investigation  of  them,  and  to  employ  various  methods  of  testing 
the  sensations  of  the  patient  so  that  the  conclusions  derived  from  one 
method  may  be  checked,  and  corrected  or  confirmed  by  the  inferences 
drawn  according  to  other  and  different  methods. 

1.  Test  of  Common  Sensations. — Cutaneous  common  sensations  may  be 
tested  by  the  prick  of  a  pin,  by  burning,  pinching,  and  firm  pressure. 
The  most  certain  method,  however,  is  the  application  of  the  faradic  cur- 
rent ;  since  it  can  be  carefully  graduated  so  as  to  determine  the  minimum 
stimulus  which  causes  a  sensation  of  pain,  while  the  sense  of  touch  is 
scarcely  if  at  all  affected  by  it.^ 

2.  Test  of  Rapidity  of  Sensory  Conduction. — It  is  sometimes  very  useful 
to  determine  the  period  which  intervenes  between  the  application  of  a 
stimulus  and  the  resulting  sensation,  inasmuch  as  we  have  seen  that  con- 
duction of  centripetal  impressions  is  retarded  in  cases  of  anaesthesia,  and 
accelerated  in  cases  of  hyperaesthesia. 

The  following  are  the  general  results  obtained  by  physiologists  for 
healthy  individuals  :  ^ 


Nature  of  Stimulus. 

Time  between  applicatiou 
of  stimulus  and  signal 
of  perception,   in  frac- 
tions of  a  second. 

Name  of  Observer. 

Shock  on  left  hand 

12 
13 
17 
13 
15 
16 
16 
15 
16 
16 
23 

Exner. 
Do. 
Do. 
Do. 
Do. 
Donders. 
Von  Wittich. 

Vintschgau  &  Honigschuied. 
Do. 
Do. 
Do. 

Shock  on  forehead 

Shock  on  toe  of  left  foot 

Sudden  noise 

Visual  impression  of  electric  spark. 
Healing  a  sound 

Current  to  tongue  causing  taste... 
Saline  tastes 

Taste  of  sugar 

Taste  of  acid 

Taste  of  quinine 

*  Leyden  (E.).     "  Untersuchung  iiber  die  Sensibilitat  im  gesunden  und  kranken 
Zustande."    Virchow's  Archiv.     Bd.  XXXI.,  1864,  p.  1. 

*  M'Kendrick  (Prof.  J.  G-.).     Outlines  of  Physiology  in  its  Kelations  to  Man. 
1878,  p.  543. 


108  ELEMENTARY  AFFECTIONS   OF 

Any  serious  departure  from  the  figures  given  in  this  scale,  either  by 
way  of  acceleration  or  retardation  would  indicate  disease.  Acceleration  of 
the  conduction  cannot  however  be  recognised  without  the  use  of  delicate 
instruments  ;  hence  it  is  only  necessary  for  practical  purposes  to  take  the 
retardation  into  account. 

3.  Tests  of  Sense  of  Pressure. — When  a  body  is  in  contact  with  any 
part  of  our  skin  we  are  not  only  conscious  of  a  sensation  of  pressure,  but 
we  also  form  a  judgment  with  respect  to  the  part  of  our  body  which  has 
been  touched,  and  the  nature  of  the  substance  touching  it.  By  sensations 
of  pressure  we  are  able  to  come  to  the  following  conclusions  ■}  (1)  We  infer 
the  existence  of  some  substance  touching  our  body ;  (2)  Variations  in  the 
intensity  of  the  pressure  exerted  helps  us  to  estimate  the  weight  of  the 
touching  body ;  (3)  The  cutaneous  surface  forms  a  tactile  field  similar  to 
the  field  of  vision,  which  enables  us  to  locahse  our  sensations  of  touch  and 
to  refer  them  to  definite  parts  of  the  surface  of  our  bodies ;  (4)  Closely 
connected  with  our  power  of  estimating  weight  from  sensations  of  pressure 
is  the  power  of  discriminating  between  two  or  more  cutaneous  points 
simultaneously  touched. 

The  sense  of  pressure  must  be  tested  by  the  method  introduced  by 
H.  Weber.2  This  method  consists  of  the  super-imposition  of  weights  in 
order  to  determine  the  smallest  difierence  which  can  be  perceived.  The 
testing  may  be  carried  on  by  ounce,  half-ounce,  and  drachm  weights,  or  by 
various  coins.  The  variations  in  the  sensations  bear  that  general  relation 
to  the  variations  in  the  super-imposed  weights  which  is  formulated  in 
Fechner's  law.  In  order  that  the  muscular  sense  may  be  excluded,  it  is 
necessary  that  the  part  of  the  body  to  be  investigated  should  rest  on  a  firm 
support,  and  the  sensation  of  temperature  must  be  excluded  by  the  inter- 
position of  a  bad  conductor  of  heat,  such  as  a  small  wooden  disc. 

Eulenburg  has  constructed  an  instrument  for  testing  the  sense  of 
pressure,  which  he  has  named  barcesthesiometer.  It  consists  essentially  of 
a  spring  balance,  constructed  so  that  varying  degrees  of  pressure  on  the 
spring  may  be  read  ofi*  on  a  dial.  By  means  of  this  instrument  Eulenbm-g 
found  that  a  diff'erential  pressure  of  ^V  to  ^'niii-  can  be  discriminated  by 
the  skin  of  the  face — the  skin  of  the  forehead  being  especially  sensitive. 
The  perception  of  difference  amounted  to  from  -ixs  to  iVin.  on  the  skin  of 
the  hand  and  arm,  on  the  anterior  aspect  of  the  thigh  and  leg,  and  on  the 
dorsum  of  the  foot ;  but  is  much  less  acute  on  the  skin  of  the  sole  of  the 
foot  and  back  of  the  leg.  When  the  afiection  is  unilateral,  so  that  one 
side  can  be  compared  with  the  other,  the  results  obtained  are  much  more 
reliable  than  when  both  are  affected,  inasmuch  as  in  the  latter  case  a 
standard  of  comparison  must  be  found  in  another  subject.  It  may  be 
mentioned  that  a  colder  weight  is  felt  to  be  heavier  than  one  of  the  same 

^  Hermann  (Prof.  L.),  Human  Physiology.  Translated  and  edited  by  A. 
Gamgee.     Second  edit.  1878,  p.  463. 

^  Weber  (E.  H.)._  ".Der  Tastsinn  und  das  Gemeingefilhl,"  Wagner's  Handworter- 
bnch  der  Physiologic.    Bd.  III. ,  s.  481  et  seq. 


INDIVIDUAL   SENSORY  MECHANISMS.  109 

temperature  as,  or  slightly  warmer  than  the  body ;  so  that  the  apparent 
difference  of  pressure  between  two  bodies  becomes  greater  when  the  heavier 
weight  is  the  colder,  and  less  when  the  lighter  weight  is  the  colder  of  the 
two.  The  sensitiveness  is  also  greater  for  an  increase  than  for  a  decrease 
of  the  difference  in  the  weights,  and  also  greater  for  a  small  absolute  than 
for  a  large  absolute  pressure. 

Goltz^  has  introduced  a  very  efficient  method  for  determining  the 
smallest  possible  variation  in  pressure,  affecting  a  cutaneous  part,  which 
can  be  perceived.  It  consists  of  an  india-rubber  tube  filled  with  water, 
and  by  rhythmical  pressure  waves  analogous  to  those  of  the  arterial  pulse 
are  produced.  In  order  to  secure  a  constant  surface  of  contact  the  tube  is 
bent  over  a  piece  of  cork  at  the  spot  which  is  intended  to  be  in  contact 
with  the  cutaneous  part  to  be  examined.  This  method  gives  the  same 
scale  of  results  as  the  experiments  of  Weber  with  the  compasses,  to  be 
mentioned  immediately,  with  the  exception  of  the  tip  of  the  tongue,  in 
which  the  sense  of  pressure,  as  determined  by  Goltz's  method,  stands  much 
lower  than  in  Weber's  scale  for  measuring  the  sense  of  locality. 

4.  Tests  of  the  Sense  of  Locality. — The  sense  of  locality  may  be  tested 
by  touching  some  part  of  the  skin  with  the  finger  or  point  of  a  needle 
whilst  the  patient's  eyes  are  closed,  and  requesting  him  to  indicate  the 
point  touched.  Acpording  to  E.  H.  Weber  the  error  in  healthy  persons  is 
about  equal  to  the  minimum  distance  at  which  the  points  of  a  pair  of 
compasses  can  be  recognised  as  separate  in  different  parts  of  the  skin. 
Weber^  found  that  the  distance  at  which  the  points  of  the  compasses  must 
be  separated  from  one  another,  in  order  to  be  felt  as  two,  varies  for  different 
regions  of  the  body.  The  results  obtained  by  Weber  were  subsequently 
confirmed  and  extended  by  Valentin.*  The  following  may  be  taken  as 
the  normal  scale,  from  which  any  marked  deviations  must  be  regarded  as 
pathological: — The  tip  of  the  tongue,  i'18  mm.;  the  extremities  of  the 
fingers,  2"25  mm. ;  the  dorsal  side  of  the  first  phalanx,  16  mm.  ;  the  back 
of  the  hand,  31  mm. ;  the  upper  arm  and  thigh,  77  mm.  The  smallest 
required  distance  is  less  in  the  transverse  than  in  the  longitudinal  direction 
in  the  limbs  ;  it  is  less  when  the  points  are  placed  on  the  skin  one  after 
the  other ;  it  is  less  when  the  surfaces  vary  in  structure,  as  the  inner  and 
outer  surface  of  the  lips  ;  it  is  less  when  beginning  with  larger  distances 
and  gradually  diminishing  the  distance  until  both  sensations  blend,  than 
when  beginning  with  the  smaller  distances  and  gradually  finding  that  dis- 
tance at  which  the  two  separate  sensations  make  their  appearance  ;  and  it 
also  becomes  smaller  by  practice.  The  power  of  discrimination  is  greater 
when  the  points  of  the  compasses  are  moved  instead  of  being  kept 
stationary ;  hence  in  testing  the  sense  of  locality  it  is  useful  to  move  the 

1  Hermann's  Physiology,  p.  465. 

*  Annotationes  Anatomicse  et  Physiologicse.  Auct.  E.  H.  Weber.  Prol.  XIII. 
Lipsiae,  1834. 

^Valentin's  Lehrbucli  der  Physiologic  des  Menschen.  Band  II.,  s.  566.  See 
also  Todd's  Cyclopaedia  of  Anatomy.  Art.  "Touch,"  by  W.  B.  Carpenter.  Vol.  IV., 
p.  1163. 


110  ELEMENTARY  AFFECTIONS   OF 

points  of  the  compasses  over  the  skin  in  two  parallel  lines,  and  to  note  the 
variations  in  the  apparent  distance  which  occur  in  different  localities. 
The  compasses  will  seem  to  the  patient  to  widen  in  the  most  sensitive 
parts,  and  to  narrow  or  blend  in  the  less  sensitive  parts.  The  points  of 
the  compasses  may  be  blunted  with  sealing-wax  ;  or  points  of  some  non- 
conducting substance,  such  as  ivory  or  wood,  may  be  used  so  as  to  eliminate 
the  efiects  of  the  sense  of  temperature.  It  may  be  mentioned  that  when 
the  points  of  the  compasses  are  just  sufficiently  separated  to  give  rise 
to  two  distinct  impressions,  if  one  of  the  points  be  pressed  forcibly,  the 
other  ceases  to  be  distinguished,  and  the  two  impressions  blend  when 
the  skin  between  the  points  is  irritated  by  tickling  or  by  induction 
currents. 

In  order  to  explain  these  phenomena  it  is  necessary  to  assume  that  the 
surface  of  the  skin  forms  a  field  of  tactile  sensibility  which  is  composed  of 
tactile  areas  or  units.  The  tactile  sensation  is  a  symbol  to  us  of  some 
external  event,  and  we  refer  the  sensation  to  its  appropriate  place  in  the 
field  of  touch.  The  spot  to  which  the  sensation  is  referred,  however,  does 
not  correspond  accurately  with  the  spot  irritated,  but  to  the  surface  of 
variable  extent  surrounding  this  point  and  which  constitutes  the  tactile 
area  or  unit.  When  two  such  areas,  which  partly  touch  or  overlap  each 
other,  are  stimulated,  they  cannot  be  separately  perceived,  and  the  separa- 
tion does  not  take  place  until  there  is  a  non-irritated  sensory  portion 
between  the  two  stimulated  areas.  These  tactile  areas,  however,  cannot 
be  regarded  as  fixed  and  as  corresponding  to  the  anatomical  distribution  of 
the  terminal  nerve  fibres,  since  such  an  area  exists  round  each  cutaneous 
point ;  and  the  improvement  by  attention  and  practice  in  the  sense  of 
touch  cannot  be  supposed  to  be  due  to  the  growth  of  new  nerve  fibres 
in  the  skin.  It  must,  therefore,  be  assumed  that  the  transmission  of  the 
irritation  of  one  nerve  fibre  to  another  nerve  fibre  in  the  neighbourhood  is 
a  central  process.  It  may  be  conjectured  that  there  are  central  sensation 
areas  corresponding  to  the  peripheral  ones  ;  and  that  it  is  by  a  more  exact 
limitation  of  these  areas  the  improvement  in  the  sense  of  locality  takes 
place. 

When  the  parts  specially  used  for  discriminating  the  finer  distinctions 
between  objects,  as  the  tips  of  the  fingers  and  the  palms  of  the  hands,  are 
to  be  tested,  the  patient  may  be  allowed  to  handle  small  common  objects, 
as  pieces  of  money  or  buttons,  and  may  be  asked  to  describe  them  with 
closed  eyes.  It  may  also  be  ascertained  whether  the  patient  can  distinguish 
by  touch  alone  a  smooth  from  a  rough  surface,  or  a  hard  from  a  soft  object, 
or  whether  he  can  with  closed  eyes  distinguish  the  head  from  the  point  of 
a  needle. 

5.  Tests  of  Sensations  of  Temperature. — When  the  temperature  of  the 
skin  is  raised  or  lowered  we  experience  sensations  of  heat  and  cold  respec- 
tively ;  and  when  the  variations  of  temperature  are  produced  by  bodies  in 
contact  with  the  skin  we  form  judgments  with  respect  to  their  temperature. 
The  range  of  most  accurate  sensation  lies  between  27°  and  33°C,  then 


INDIVIDUAL  SENSORY  MECHANISMS.  Ill 

between  33°  and  39°C,  and  lastly  between  14°  and  27°C.  Variations 
above  and  below  these  limits  are  no  longer  specifically  felt,  but  produce 
general  sensations  rapidly  rising  to  pain.^  The  change  in  temperature 
is  felt  more  intensely  the  more  rapid  its  occurrence,  and  the  larger  the 
affected  surfaces. 

The  sense  of  temperature  may  be  roughly  tested  by  the  application  of 
hot  and  cold  bodies  ;  but  various  means  have  been  adopted  to  ensure 
greater  accuracy  and  delicacy.  A  ready  and  delicate  test  is  to  see  whether 
the  patient  can  distinguish  with  certainty  between  a  cool  current  of  air, 
such  as  may  be  produced  by  blowing  upon  the  part  from  a  distance,  and  a 
warm  one  produced  by  breathing  upon  it  in  close  proximity.  Another 
method  is  to  put  the  part  successively  into  water  of  various  temperatures, 
so  as  to  determine  the  smallest  difference  of  temperature  which  can  be 
perceived.  Weber  employed  for  this  purpose  small  phials  filled  with  oil  of 
known  temperature.  In  practice  it  is  more  convenient  to  use  two  test 
tubes,  one  filled  with  cold  and  the  other  with  warm  water.  Both  Nothnagel 
and  Eulenburg  have  constructed  ihermcesthesiometers  for  this  purpose. 
Nothnagel  found  the  smallest  perceptible  difference  of  temperature  to  be 
the  following  : — On  the  breast,  0'4"  ;  on  the  back,  0*9°  ;  back  of  the  hand, 
0  3° ;  palm  of  the  hand,  0  4° ;  arm,  0'2° ;  back  of  the  foot,  0*4 ;  lower 
extremity  from  0-5°— 0-6° ;  cheek,  0-4°— 0-2°;  the  temples,  0-4°— 0-3°. 
These  results  agree  in  the  main  with  what  had  previously  been  ascer- 
tained by  Weber. 

§  48.  Cutaneous  Ancesthesia. 

Cutaneous  AnaBsthesia  is  characterised  by  diminution  or 
abolition  of  the  function  of  the  cutaneous  sensory  mechanism. 
When  the  sensibility  to  pain  is  diminished  or  abolished  the 
condition  is  designated  Analgesia  or  Analgia,  and  Eulenburg 
has  proposed  to  call  the  condition  in  which  tactile  sensibility  is 
alone  affected  by  the  name  of  Apselaphesia. 

Diminution  of  tactile  sensibility  is  not  necessarily  associated 
with  a  corresponding  condition  of  common  sensibility.  Dimi- 
nution or  abolition  of  tactile  sensibility  may  indeed  be  associated 
with  cutaneous  hyperalgesia;  and,  conversely,  cutaneous  anal- 
gesia may  be  associated  with  increased  acuteness  of  tactile 
sensibility.  And  even  the  various  forms  of  tactile  sensibility, 
or  the  senses  of  pressure,  of  temperature,  and  of  locality,  are 
not  always  equally  affected,  since  one  or  more  of  them  may  be 
weakened  or  abolished  while  the  others  remain  unaffected  or 
even  increased. 

'  Nothnagel.  "  Beitrage  zur  Physiologic  und  Pathologic  des  Temperatursinns." 
Deutschca  Arch.  f.  Klin.  Med.     Bd.  IT.,  1867,  p.  284. 


112  ELEMENTARY  AFFECTIONS   OF 

Total  and  Partial  Sensory  Paralyses. — If  all  forms  of 
cutaneous  sensibility  are  lost,  then  the  condition  is  called  total 
sensory  paralysis;  but  if  the  tactile  sensations  are  diminished 
or  abolished  while  the  common  sensations  are  preserved,  or, 
conversely,  if  the  common  are  lost  while  the  tactile  sensations 
are  preserved,  the  condition  is  called  partial  sensory  "paralysis. 
And,  again,  if  one  or  more  of  the  tactile  or  common  sensations 
are  weakened  or  lost  while  others  are  preserved,  the  conditions 
are  called  respectively  partial  tactile  paralysis  and  "partial 
paralysis  of  common  sensation.  All  possible  combinations  of 
partial  paralysis  of  the  various  forms  of  sensation  have  been 
observed  and  described ;  but  the  most  usual  combination 
observed  is  the  loss  of  the  sensation  of  pain  (analgesia),  with 
complete  preservation  of  the  tactile  sensibility. 

§  49.  Symptoms. — Diminution  or  loss  of  cutaneous  sensi- 
bility declares  itself  by  the  statements  and  gestures  of  the 
patient.  The  statements  of  the  patient  are  often  very  vague, 
and  can  only  be  relied  upon  when  they  are  made  in  answer  to 
the  definite  tests  which  have  already  been  described.  These 
tests  must  be  methodically  applied,  in  order  to  determine 
whether  every  form  of  cutaneous  sensibility  is  affected,  or 
whether  one  or  more  of  the  forms  of  sensation  are  alone 
implicated.  The  extent  and  degree  of  ansesthesia  must  also  be 
determined.  Diminution  or-  loss  of  tactile  sensibility  must  be 
determined  by  applying  the  tests  for  the  senses  of  pressure, 
temperature,  and  locality ;  while  diminution  or  loss  of  the 
common  sensations  must  be  determined  by  pinching,  tickling, 
application  of  the  faradic  brush,  and  pricking  with  a  needle. 

In  the  higher  degrees  of  ansesthesia  the  patient  feels  as  if  his 
limbs  were  altogether  absent,  and  as  if  in  walking  he  stepped 
on  air.  The  usual  sensations  are  wanting  during  manual  labour, 
and  small  objects  fall  out  of  the  hands  unless  the  patient  con- 
trols their  action  by  means  of  the  sense  of  sight. 

Associated  Symptoms. — The  symptoms  of  ansesthesia  arise 
partly  from  the  diminution  or  abolition  of  normal  sensations 
and  partly  from  associated  conditions.  When  cuta^neous  sensi- 
bility is  diminished  the  patient  frequently  complains  of  various 
parsesthesise,   as   "  numbness,"   "  furriness,"  "  crawling,"  or  for- 


INDIVIDUAL  SENSORY  MECHANISMS.  113 

mication.  The  patient  feels  at  times  as  if  his  fingers  were 
covered  with  gloves,  or  as  if  something  were  between  the  skin 
and  the  bodies  touching  it.  During  walking  the  patient  may- 
feel  as  if  he  were  stepping  on  wool  or  on  a  carpet  or  on  bladders 
filled  with  water. 

Pain  is  frequently  associated  with  anaesthesia  when  the 
affection  is  caused  by  injury  to  the  peripheral  nerves.  The 
irritation  which  causes  the  pain  is  situated  in  a  part  of  the 
sensory  nerve  above  the  point  where  its  conduction  is  inter- 
rupted ;  but.  in  accordance  with  the  law  of  eccentric  projection, 
the  pain  is  referred  to  the  surface.  When  severe  pain  has 
been  felt  in  the  anaesthetic  part  the  condition  has  been  called 
ancBsthesia  dolorosa.  It  is  sometimes  difficult  to  determine 
whether  a  particular  case  is  to  be  regarded  as  one  of  anaesthesia 
neuralgia,  or  motor  paralysis,  inasmuch  as  the  symptoms  charac- 
teristic of  each  affection  are  combined  in  various  ways.  The 
special  senses  are  sometimes  affected,  especially  when  the  cause 
of  the  anesthesia  is  central,  or  when  the  disease  is  situated  in 
nerves  which  contain  fibres  of  special  sense,  as  the  lingual  nerve. 
Loss  of  taste  and  of  smell  are  the  most  common  affections  of 
special  sense  which  are  associated  with  ansesthesia ;  loss  of 
bearing  is  less  frequent,  and  loss  of  sight  is  rare. 

§  50.  Distribution  of  Anesthesia. 

(1)  Circumscribed  Ancesthesia. — In  this  form  the  sensory 
paralysis  is  limited  to  the  district  supplied  by  certain  nerve 
trunks,  or  it  may  even  be  limited  to  small  circumscribed 
patches  of  the  skin.  The  lesions  which  give  rise  to  this  form 
may  be  situated  in  the  course  of  the  nerves,  their  peripheral 
terminations,  or  posterior  roots. 

(2)  Anaesthesia  in  the  Form  of  a  Girdle. — In  this  form  of 
the  affection  a  zone  of  varying  width  surrounding  the  body  on 
one  or  both  sides  is  found  to  be  anaesthetic.  This  zone  may  be 
situated  at  various  levels,  and  may  therefore  pass  round  the  pel- 
vis, abdomen,  thorax,  or  even  the  region  of  the  shoulder  or  neck. 
It  is  caused  by  disease  of  the  spinal  cord  or  of  its  membranes 
having  only  a  limited  longitudinal  extent,  and  implicating  the 
posterior  roots  of  the  nerves  or  the  posterior  grey  cornua. 

(3)  Para-anoisthesia. — At  times  the  anaesthesia  is  limited  to 
VOL.  I.  'I 


114  ELEMENTARY   AFFECTIONS   OF 

the  lower  extremities  and  lower  half  of  the  body,  and  the 
affection  may  then  be  called  para-ancesthesia.  The  affection 
may  at  times  be  unilateral  or  limited  to  one  extremity  or 
portion  of  the  trunk.  This  variety  is  usually  caused  by  diseases 
of  the  spinal  cord,  which  destroy  a  portion  of  it  more  or  less 
completely  in  a  transverse  direction,  and  thus  prevent  afferent 
impulses  being  conveyed  to  the  cerebrum ;  but  it  is  sometimes 
of  functional  origin,  and  then  is  associated  with  hysteria. 

(4)  Hemi-ancesthesia. — The  anaesthesia  may  be  distributed 
over  the  entire  half  of  the  body,  face  and  extremities  included, 
the  anaesthetic  parts  being  usually  separated  from  the  healthy 
parts  by  the  median  line.  In  these  cases  the  special  senses,  as 
well  as  the  accessible  mucous  membranes,  are  usually  impli- 
cated in  the  affection,  taste  and  smell  being  abolished  on  the 
anaesthetic  side,  but  the  acuteness  of  hearing  and  vision  on 
that  side  is  only  diminished,  not  abolished.  In  this  variety  of 
anaesthesia  the  lesion  is  generally  situated  in  the  posterior  part 
of  the  optic  thalamus,  and  interferes  with  conduction  through 
the  fibres  of  the  posterior  third  of  the  internal  capsule,  and  the 
optic  radiations  of  Gratiolet.  This  variety  is  also  often  func- 
tional, and  is  then  of  hysterical  origin. 

§  51.  Varieties  of  Partial  Sensory  Paralysis. 

(1)  Analgesia. — The  most  usual  form  of  partial  sensory 
paralysis  is  that  in  which  the  sense  of  pain  is  abolished  while 
the  other  forms  of  sensibility  are  either  unaffected,  or  only 
affected  to  a  slight  extent.  Analgesia  may  be  circumscribed  or 
distributed  over  the  lower  half  of  the  body,  a  condition  which 
may  be  called  para- analgesia,  or  implicate  the  lateral  half, 
constituting  heini-analgesia. 

(2)  Thermo-Ancesthesia. — Insensibility  to  heat  or  cold  may 
at  times  occur  as  an  isolated  affection.  When  the  sense  of 
temperature,  however,  is  the  only  one  affected,  its  loss  is  usually 
limited  to  more  or  less  circumscribed  portions  of  the  skin,  as 
that  over  the  backs  of  the  feet  and  of  the  legs. 

(3)  Tactile- AncBsthesia. — When  there  is  loss  of  tactile  sense 
■without  any  other  affection  of  sensibility,  the  anaesthesia  is 
generally  found  distributed  in  patches  over  the  skin  of  the 
lower  extremities.      The  degree  of  tactile  sensibility  must  be 


INDIVIDUAL  SENSORY  MECHANISMS.  115 

estimated  by  a  methodical  application  of  the  tests  already 
described.  Of  all  the  diseases  which  give  rise  to  partial  forms 
of  paralysis,  locomotor  ataxy  is  the  most  common  and  impor- 
tant. In  this  affection  the  posterior  roots  of  the  nerves  are 
diseased  ;  but  the  disease  being  chronic  and  progressive  the 
root-fibres  are  implicated  gradually  and  successively,  and  not 
simultaneously. 

(4)  Retardation  of  Conduction  in  Partial  Sensory  Para- 
lysis.— Retardation  of  sensory  conduction  was  first  observed  by 
Cruveilhier^  as  a  symptom  of  spinal  disease.  This  condition 
may  be  employed  as  a  test  of  any  form  of  anaesthesia,  but  in 
the  partial  varieties  it  gives  rise  to  several  anomalous  pheno- 
mena which  demand  separate  mention. 

{a)  Separation  of  Tactile  and  Painful  Impressions. — 
Leyden,^  Remak,^  and  several  other  authors  have  drawn  attention 
to  the  fact  that  in  cases  of  locomotor  ataxy  the  prick  of  a  needle 
causes  a  prompt  feeling  of  touch,  which  is  frequently  followed  in 
two  or  three  seconds  by  a  feeling  of  pain.  In  cases  of  thermo- 
ansesthesia,  a  test  tube  holding  hot  water  may  at  first  give  rise 
to  an  immediate  feeling  of  touch,  to  be  followed  in  two  or  three 
seconds  by  a  sensation  of  temperature. 

(6)  Double  Painful  Sensations. — Another  curious  sensory 
phenomenon  has  been  described  by  Naunyn.*  He  noticed  in 
several  cases  of  locomotor  ataxy  that  pricking  the  skin  on  the 
back  of  the  foot  with  a  needle  was  followed  by  a  first  painful 
sensation,  and  when  this  had  subsided  by  a  second  painful 
sensation,  the  latter  being  usually  of  greater  intensity  and  longer 
duration  than  the  former.  The  first  is  felt  after  a  lapse  of  two 
and  a  half  to  three  seconds  subsequent  to  the  prick,  but  the 
second  is  not  felt  until  after  another  interval  of  from  two  to  five 
seconds.  He  found  that  the  patients  did  not  always  experience 
a  distinct  interval  between  the  two  sensations,  and  this  blendinsf 

'  Cruveilhier.     Anat.  Patholog.,  XXXVIII.,  p.  9. 

^  Leyden  (E.).  Die  graue  Degeneration  der  hintern  Riickenmarksstrange. 
Berlin,  1863.  p.  200  et  seq.  "  Zur  grauen  Degeneration  der  hintern  Riickenmarks- 
strange."   Virchovv's  Arch.     Bd.  LX.,  p.  188. 

"  Remak  (E.).  "Ueber  Zeitliche  Incongruenz  der  Berilhrungs  nnd  Schmerz- 
empfindung  bei  Tabes  dorsalis,"    Arch.  f.  Psychiat.     Bd.  IV.,  1874,  s.  763. 

"  Naunyn.  "Ueber  eine  eigenthiimUche  Anomalie  der  Sohmerzempfindung." 
Arch.  f.  Psychiat.  Bd.  IV.,  1874,  s.  760.  See  also  Deutsches  Arch.  f.  klin.  Med. 
Bd.  XXIIi.    Leipzig,  1879,  s.  414. 


116  ELEMENTARY  AFFECTIONS   OF 

of  two  sensations  which  are  occasionally  distinct  leads  us  to 
mention  one  or  two  other  anomalies  which  are  probably  due  to 
retarded  conduction,  and  are  at  least  found  under  the  same 
physical  conditions. 

(c)  Persistent  after-Sensations. — In  cases  of  partial  angesthesia, 
when  the  skin  of  the  patient  is  pinched  or  pricked  with  a  needle, 
the  resulting  sensation  begins  more  slowly  than  in  health,  but 
gradually  increases  in  intensity,  is  more  severe,  and  much  slower 
in  its  disappearance.  The  fact  that  the  sensation  begins 
more  promptly  on  the  sound  than  on  the  diseased  side  shows 
that,  in  the  case  of  the  latter,  sensory  conduction  is  retarded. 
But  retardation  of  conduction  means  increase  of  the  specific 
resistance  of  the  afferent  conducting  apparatus,  which,  in  its 
turn,  means  that  the  impulses  which  reach  the  cortex  of  the 
brain  on  the  diseased  must  be  stronger  than  on  the  healthy  side 
in  order  to  overcome  that  resistance,  and,  being  stronger,  they 
give  rise  to  severer  and  more  persistent  pain. 

(d)  Inability  to  Count  Successive  Impressions. — Closely 
connected  with  these  persistent  after-sensations  is  the  inability 
of  the  patient  to  count  correctly  several  impressions  made  in 
quick  succession.  Enumeration  of  successive  impressions  pre- 
supposes an  interval  to  elapse  between  the  sensation  caused  by 
each,  but  when  the  conduction  is  retarded  each  sensation  is 
unusually  prolonged  so  that  the  one  does  not  fade  before  the 
other  begins  and  counting  becomes  impossible.  Schiff'^  has 
shown,  experimentally,  that  a  transverse  narrowing  of  the  grey 
substance  causes  a  retardation  of  the  conduction  of  sensation, 
the  degree  of  which  corresponds  closely  with  the  amount  of  the 
grey  substance  destroyed.  It  may,  therefore,  be  presumed  that 
wherever  retarded  sensation  exists  there  is  disease  of  the 
posterior  grey  cornua  of  the  spinal  cord  ;  a  supposition  which 
also  explains  why  the  retardation  affects  by  preference  the  sense 
of  pain. 

§  52.  Cutaneous  Hyperesthesia. 

Increase  of  the  Tactile  Sensibility  (Hyperpselaphesia). — 
Abnormal  acuteness  of  tactile  sensibility — to  which  Eulenburg 
has  given  the  name  of  Hyperpselaphesia — declares  itself  by 

>  Schiff  (J.  M.).    Lehrbuch  der  Physiologie  des  Menschen.    1858-59.    p.  245. 


INDIVIDUAL   SENSORY  MECHANISMS.  117 

excessive  reaction  to  the  various  methods  already  described  for 
testing  the  senses  of  pressure  and  locality.  The  sensibility  to 
minimum  differences  of  pressure  may  be  excessive,  so  that  a 
much  smaller  difference  than  usual  is  perceptible.  The  dia- 
meters of  the  areas  of  sensibility  may  also  be  unusually  small. 
Increase  of  the  sense  of  locality  is  sometimes  observed  in  acute 
cutaneous  affections,  such  as  in  vesication,  erysipelas,  and  herpes 
zoster ;  and  it  may  or  may  not  be  associated  with  a  correspond- 
ing increase  of  the  sense  of  temperature,  and  of  the  cutaneous 
common  feelings. 

(a)  Polycesthesia. — Brown-Sdquard  first  drew  attention  to  the 
fact  that  under  some  circumstances  one  point  of  the  compass  is 
felt  by  the  patient,  on  being  placed  on  the  skin,  as  two,  three, 
or  five  points.  Fischer  proposes  to  call  this  condition  Poly- 
cesthesia} 

(b)  Allochiria. — A  peculiar  sensory  phenomenon,  first  de- 
scribed by  Obersteiner,^  consists  of  the  fact  that  the  patient  is 
not  sure  and  is  often  in  error  as  to  which  side  of  the  body  has 
been  touched,  even  although  the  cutaneous  sensibility  is  more 
or  less  completely  retained. 

Local  hyperaestliesia  of  the  tactile  sensibility  may  be  induced  experi- 
mentally. On  passing  a  moderate  constant  current  tbrougb  the  skin, 
increase  of  the  sense_  of  locality  may  be  found  at  the  cathode  (Suslowa). 
When  local  aneemia  is  artificially  produced  by  an  extremity  being  main- 
tained in  an  elevated  position,  the  sense  of  temperature  is  increased,  while 
there  is  a  diminution  of  the  sense  of  locality  in  the  affected  portions  of 
skin.  The  tactile  sensibility  is  also  increased  by  carbonic  acid  baths,  and 
by  chloride  of  sodium  and  sea  baths. 

It  is  very  probable  that  many  cases  of  nervous  palpitations  and  of  the 
sensation  of  pulsation  in  many  of  the  arteries  of  the  body  are  due  to  a 
hypereesthesia  of  the  sense  of  pressure. 

§  53.  Distribution  of  Hypercesthesia. — The  distribution  of 
hypersesthesia  is  more  or  less  similar  to  that  of  anaesthesia.  It 
may  occur  in  more  or  less  circumscribed  patches,  or  be  limited 
to  the  distribution  of  individual  nerves,  or  it  may  implicate  the 
lower  half  or  the  lateral  half  of  the  body,  just  as  has  already 
been    described    with    respect  to   anaesthesia.     Hypersesthesia 

1  Deutsches  Arch.  f.  klin.  Med.    Bd.  XXVI.     Leipzig,  18S0.    p.  114. 
^  Brain.     Vol.  IV.     London,  1881.     p.  153. 


118  ELEMENTARY   AFFECTIONS   OF 

frequently  precedes  anaBsthesia;  and,  as  previously  observed, 
some  forms  of  sensibility  may  be  in  excess,  while  others  are 
greatly  diminished. 

Girdle  Sensation. — A  subjective  perception  which  produces 
the  impression  of  having  a  girdle  or  a  broad  bandage  tied  about 
the  trunk  or  limbs  is  a  very  common  accompaniment  of  all  spinal 
diseases.  When  situated  at  the  upper  part  of  the  thorax,  it  may 
be  accompanied  with  a  severe  sense  of  pressure,  and  is  always 
very  troublesome  to  the  patient.  It  may  occupy  different  levels 
on  the  trunk,  but  may  also  attack  various  parts  of  the  lower  ex- 
tremities, particularly  in  the  region  of  the  ankle  and  knee,  of  one 
or  both  sides.  The  sensation  is  probably  produced  by  a  slight 
excitation  of  the  entering  posterior  roots  in  those  cases  in  which 
the  spinal  affection  is  limited  in  its  longitudinal  extent.  It 
usually  accompanies  inflammatory  or  other  morbid  conditions  of 
the  cord,  and  originates  with  the  root-fibres  which  occupy  the 
upper  limit  of  the  disease.  Any  sort  of  local  disease  of  the  cord 
and  its  neighbouring  parts  which  irritates  the  posterior  roots  to 
a  moderate  extent  may  produce  the  symptom. 

§  54.  Cutaneous  Thermo-Hypercesthesia. — The  sensibility  to 
minimum  differences  of  temperature  may  be  in  excess.  This 
occurs,  for  instance,  when  the  epidermis  is  removed  by  vesication, 
and  in  cases  of  herpes  zoster.  In  the  early  stages  of  tabes  dorsalis 
the  sense  of  temperature  is  often  abnormally  acute.  Patients 
who  suffer  from  other  forms  of  sensory  irritation  often  complain 
of  an  intense  feeling  of  burning  or  of  cold,  and  Brown-Sequard 
thinks  that  these  sensations  are  caused  by  disease  of  the  fibres 
of  the  grey  substance  of  the  spinal  cord,  which  conduct  sensations 
of  temperature.  Schiff  attributes  these  sensations  to  vaso-motor 
disturbances  taking  place  in  parts  already  rendered  hypersesthetic. 

(1)  Causalgia,. — The  distressing  pain  which  Weir  Mitchell 
has  named  Causalgia  appears  to  belong  to  the  thermo-hyper- 
oesthesioe.  This  pain  is  variously  described  by  patients  as 
"  burning,"  or  as  "  mustard  red  hot,"  or  as  a  "  red  hot  file  rasping 
the  skin."^  It  is  generally  associated  with  glossy  skin,  but 
often  precedes  the  trophic  changes  of  the  skin. 

'  Injuries  of  Nerves  and  their  consequences,  by  Dr.  Weir  Mitchell.  Lond., 
1872.     p.  272. 


INDIVIDUAL  SENSORY  MECHANISMS.  119 

(2)  Di/scesthesia. — Under  the  term  dyscBsthesia  Charcot^  de- 
scribes a  sensation  of  a  peculiarly  distressing  and  vibratory 
character,  which  ascends  towards  the  central  end  of  the  limb, 
and  descends  towards  its  extremity.  The  sensation  is  elicited 
by  the  slightest  touch  or  the  application  to  the  limb  of  a  cold 
body,  and  it  persists  several  minutes  or  even  a  quarter  of  an 
hour  after  the  exciting  cause  has  ceased  to  act.  After  some 
little  period  of  time  has  elapsed  an  analagous  sensation  may  be 
felt  at  a  corresponding  point  of  the  limb  opposite  to  the  one 
primarily  excited. 

(3)  Hypercesthetic  Spots. — During  the  paroxysms  of  lightning 
pains  in  locomotor  ataxy,  circumscribed  patches  of  the  skin, 
generally  of  the  lower  extremities,  become  exquisitely  painful 
to  touch.  These  patches  are  also  subject  to  attacks  of  sponta- 
neous pains  of  a  burning  character.  One  patient,  in  describing 
this  pain,  compared  it  to  the  sensation  that  might  be  caused  by 
rubbing  into  the  skin  a  burning  vesuvian  match. 

§  55.  Cutaneous  Hyperalgesia, 

Increased  sensibility  of  the  common  sensations  is  much  more 
usual  than  increase  of  tactile  sensibility.  In  conditions  of  irri- 
tation of  the  sensory  nerves  stimuli,  such  as  tickling,  which  only 
give  rise  to  the  slighter  forms  of  common  sensibility  in  healthy 
persons,  now  give  rise  to  pain ;  and  even  stimuli,  which  in  health 
give  rise  to  tactile  sensations,  become  distressing.  The  contact 
of  the  skin  in  health  with  a  cold  body  gives  rise  to  a  sensation  of 
temperature,  but  not  to  pain ;  but  in  conditions  of  irritation 
of  the  sensory  nerves  such  contact  gives  rise  to  pain,  while  the 
acuteness  of  the  sense  of  temperature  itself  is  diminished ;  and 
the  slightest  contact  with  a  body,  which  gives  rise  to  scarcely 
any  sensation  of  pressure  in  a  healthy  person,  may  become  ex- 
quisitely painful  under  these  circumstances. 

Lightning  Pams.  — Besides  the  pain  caused  by  the  contact  of 
ordinary  substances  with  the  surface,  intensely  distressing  pains, 
occurring  more  or  less  spontaneously  and  in  paroxysms,  are 
amongst  the  most  characteristic  symptoms  of  locomotor  ataxy. 
They  are  likewise  present,  not  only  in  other  organic  diseases  of 

1  Lemons  snr  les  Maladies  du  Systeme  Nerveux,  par  J.-M.  Charcot.  Tome  II. 
Paris,  1877.    p.  116. 


120  ELEMENTARY  AFFECTIONS  OF 

the  spinal  cord  and  its  membranes,  but  also  in  functional  affec- 
tions ;  such  as  spinal  irritation  and  neurasthenia.  These  pains 
have  been  described  under  the  name  of  general  neuralgia  or 
neuralgic  rheumatism,  and  are  compared  by  the  patients  to 
forked  lightning  darting  through  the  body ;  hence  they  are  called 
lightning-like  or  lancinating  pains.  They  usually  come  on  in 
paroxysms,  which  recur  at  irregular  intervals.  The  paroxysm 
often  begiDS  without  any  apparent  exciting  cause,  but  at  other 
times  the  attack  is  induced  by  bodily  exertion,  emotional  dis- 
turbance, the  act  of  coition,  gastric  disturbances,  or  variations 
of  temperature. 

§  56.  Cutaneous  Paralgesia. 

(1)  Pruritus. — Cutaneous  pruritus  is  a  sensation  which  is 
evidently  caused  by  abnormal  irritation  of  the  nerve  ends  of  the 
papillae  of  the  skin,  or  by  a  state  of  undue  irritability  of  these 
nerve  terminations  themselves.  Pruritus  is  related  to  such  sen- 
sations as  tickling,  and  to  burning  and  stinging  pains,  but  in  the 
former  there  is  an  irresistible  tendency  to  scratch  the  affected 
part.  Pruritus,  or  itching,  is  a  symptom  of  various  skin  affections, 
and  it  is  a  specially  prominent  feature  of  scabies  and  other 
parasitic  affections.  Very  violent  pruritus  may  also  be  present 
in  affections  of  the  papillse  in  the  absence  of  any  cutaneous 
eruption.  Obstinate  itching  is  also  a  troublesome  symptom  of 
diseases  in  which  certain  chemical  agents  are  circulating  in  the 
blood,  as  jaundice  and  diabetes. 

(2)  Formication  is  usually  caused  by  an  abnormal  condition, 
not  of  the  peripheral  nerve  ends,  but  of  the  nerve  trunks  and 
central  sensory  organs.  The  essential  condition  which  gives  rise 
to  the  sensation  appears  to  be  some  anomaly  of  the  conduction 
apparatus,  which  causes  the  currents  to  pass  through  the  centri- 
petal fibres,  not  simultaneously,  but  in  quick  succession  and  with 
variable  intensity.  The  sensation  does  not  amount  to  pain,  but 
is  described  as  a  feeling  of  creeping  or  pricking,  or  is  compared 
to  the  crawling  of  ants.  Formication  occurs  as  a  transitory 
symptom  in  minor  mechanical  injuries  of  nerve  trunks,  such  as 
of  the  ulnar  nerve  in  contusions  of  the  elbow.  It  is  felt  in  the 
foot  as  a  sensation  of  "  pins  and  needles,"  or  "  sleepy  sensation," 
when  the  sciatic   nerve  is  compressed   for  some  time.     Com- 


INDIVIDUAL   SENSORY  MECHANISMS.  121 

pression  of  the  brachial  plexus  also  causes  similar  sensations  in 
the  upper  extremity. 

Formication  is  also  met  with  in  diseases  of  the  spinal  cord, 
more  especially  in  tabes  dorsalis,  and  likewise  in  cerebral  affec- 
tions, as  hysteria  and  hypochondriasis.  It  may  be  produced  by 
poisons  circulating  in  the  blood,  as  morphia,  veratine,  ergotine, 
and  probably  also  the  poison  of  gout. 

§  57.  Neuralgia. 

Neuralgia  consists  of  periodic  attacks  of  severe  pain,  occurring 
suddenly  and  spontaneously  in  the  course  of  one  of  the  larger 
nerve  trunks,  and  ramifying  in  all  or  a  few  only  of  its  terminal 
branches. 

(1)  General  Symptoms. — The  various  forms  of  neuralgia  are 
generally  preceded  by  premonitory  symptoms,  which  are  more 
or  less  strongly  marked.  Slight  twitching,  formication,  pricking 
sensations,  or  even  pain  is  felt  in  the  nerve-region  about  to  be 
affected,  and  sometimes  there  is  a  feeling  of  general  indisposition. 
The  condition  of  the  patient  at  the  time  of  the  first  attack  is 
always,  as  Dr.  Anstie^  has  pointed  out,  one  of  debility,  either 
general  or  special.  Patients  are  frequently  attacked  for  the  first 
time  after  an  exhausting  illness  or  fatigue,  or  when  they  are  in 
an  anxious  condition  from  some  cause  or  another. 

There  is  always  a  degree  of  suddenness  in  the  onset  of 
neuralgia.  Usually  the  first  warning  is  a  sudden,  not  very 
severe,  and  transient  dart  of  pain.  The  patient  has  probably 
been  suffering  from  some  degree  of  general  fatigue  and  malaise, 
and  the  skin  of  the  affected  part  has  been  somewhat  numb, 
when  a  sudden  stitch  of  pain  darts  along  the  nerve.  It  ceases 
immediately,  but  in  a  few  seconds  or  minutes  returns,  and  then 
darts  of  pain  recur  more  and  more  frequently,  until  at  last 
they  blend  together,  so  that  the  patient  suffers  continuous  and 
violent  pain  for  a  minute  or  so,  then  experiences  a  short  inter- 
mission ;  but  the  pain  returns  again,  and  so  on.  These  inter- 
mittent spasms  of  pain  go  on  recurring  for  one  or  several  hours, 
then  the  intermissions  become  longer,  the  pains  abate,  and  at 
last  the  attack   wears  itself  out.      The  intensity  of  the   pain 

1  Anstie  (Dr.  F.  E.).  Neuralgia  and  the  Diseases  that  resemble  it.  London, 
1871.    p.  8. 


122  ELEMENTAEY  AFFECTIONS   OF 

during  the  paroxysm  may  vary  from  moment  to  moment,  and  it 
may  become  so  intense  that  the  patient  is  almost  driven  to 
desperation. 

The  pain  is  described  as  tingling,  tearing,  boring,  stabbing, 
dragging,  burning,  or  lightning-like,  and  it  may  be  felt  as  if  it 
were  on  the  surface  or  deep  in  the  bones.  In  some  cases  the 
pain  shoots  from  the  centre  to  the  periphery,  forming  descend- 
ing neuralgia ;  while  at  other  times  it  takes  the  reverse  course, 
forming  ascending  neuralgia.  The  locality  of  the  pain  varies  : 
sometimes  it  is  in  a  fixed  spot,  while  at  other  times  it  changes 
about ;  and  it  is  often  directly  referred  to  a  nerve  trunk  which 
is  painful  throughout  its  whole  course.  The  pain  of  neuralgia 
is  usually  increased  by  movement,  so  that  the  patient  keeps 
the  affected  part  as  much  as  possible  at  rest,  although  occa- 
sionally it  is  relieved  by  movement  of  the  part.  Superficial 
irritation  of  the  skin  frequently  produces  an  attack  of  pain,  but 
continuous  firm  pressure  on  the  part  relieves  it. 

(2)  Painful  Points. — These  points  were  first  described  by 
Valleix,^  under  the  name  of  ''points  douloureux"  An  examina- 
tion of  the  part  during  an  attack  of  superficial  neuralgia  will 
reveal  one  or  more  points  which  are  extremely  sensitive  to  the 
pressure  of  the  tip  of  the  finger.  The  sensitiveness  of  these 
points  stands  almost  in  a  direct  relation  with  the  severity  of 
the  paroxysm,  but  occasionally  they  may  be  present  during  the 
period  of  remission ;  in  some  instances  pressure  on  them  pro- 
duces an  attack.  These  tender  spots  are  found  at  various  points 
in  the  course  of  the  affected  nerves,  where  their  trunks  paf^s 
from  a  deeper  to  a  more  superficial  level,  and  especially  where 
they  emerge  from  bony  canals  or  pierce  fibrous  fasciae,  or  even 
when  the  nerves  lie  on  a  hard  bed,  so  that  they  may  be  easily 
compressed.  Anstie^  found  that  the  painful  spots  were  absent 
in  the  early  stage  of  neuralgia,  and  that  they  appeared  for  the 
first  time  only  at  the  situations  of  severest  neuralgic  pain. 

(3)  Point  apophysaire. — Trousseau^  insists  that  in  all  forms 
of  neuralgia  the  spinous  processes  of  the  vertebrae  corresponding 

^  Traits  des  ndvralgies  ou  affect,  doul.  des  nerfs.     Paris,  1841. 

^  Anstie  (Dr.  F.  E,).  Neuralgia  and  the  Diseases  tbat  resemble  it.  London, 
1871.     p.  10. 

^  Trousseau's  Clinical  Medicine.  Translated  by  P.  Victor  Bazire.  Third  edition. 
New  Syd.  Soc.    Vol.  I.    London,  1868.    p.  48G. 


INDIVIDUAL   SENSORY  MECHANISMS.  123 

to  the  origin  of  the  painful  nerve,  and  which  he  calls  "points 
apophysaire,  or  spinous  points"  are  painful  on  pressure;  but 
these  points  are  also  present  in  cases  of  "  spinal  irritation"  and 
in  myalgia  (Anstie). 

(4)  Concomitant  Sensory  Symptoms. — During  the  height  of 
the  neuralgic  paroxysm  there  is  frequently  an  irradiation  of 
the  pain  to  other  sensory  nerves,  generally  to  branches  of  the 
same  trunk  or  to  neighbouring  nerves,  but  occasionally  to  more 
or  less  distant  nerves.  When,  for  instance,  one  branch  of  the 
fifth  is  primarily  affected,  the  pain  spreads  to  the  two  others ; 
next  in  frequency  from  one  nerve  as  the  sciatic  to  the  corre- 
sponding one  on  the  opposite  side  ;  and  lastly  to  quite  different 
nerve  territories,  as  from  one  of  the  intercostal  nerves  to  the 
fifth.  These  radiated  pains  are  not  usually  so  intense  as  the 
original  one ;  the  duration  of  the  attack  is  not  so  long ;  they 
begin  to  be  felt  when  the  paroxysm  has  reached  its  height,  and 
disappear  before  it  has  completely  subsided.  Various  subjective 
sensations,  as  formication,  creeping,  and  numbness,  are  felt  in 
the  region  to  which  the  affected  nerve  is  distributed  during  the 
remission ;  but  during  the  paroxysm  their  presence  is  obscured 
by  the  severity  of  the  pain.  More  marked  disturbances  of  sen- 
sibility, as  hypersesthesia  or  anaesthesia,  are  also  frequently  met 
with  in  the  affected  region  (Tiirck^).  NothnageP  has  found 
that  in  neuralgia  of  the  nerves  of  the  extremities,  without  any 
discoverable  anatomical  lesions,  an  alteration  of  the  tactile 
sensibility  of  the  skin  is  invariably  present.  As  a  rule,  in  recent 
neuralgia  having  a  duration  of  from  two  to  eight  weeks,  there  is 
hyperalgesia  of  the  skin,  and  in  neuralgia  of  long  standing 
ancesthesia.  These  symptoms  are  usually  limited  to  the  region 
of  distribution  of  the  affected  nerve  ;  but  in  some  cases  of 
limited  neuralgia  the  disturbances  of  sensibility  affect  the  whole 
of  that  side  of  the  body. 

(5)  Various  motor,  vaso-motor,  secretory,  trophic,  and  psychical 
symptoms  are  associated  with  neuralgia,  but  our  main  object  at 

1  Tiirck  (L.).  "  Beitr.  zur  Lebre  v.  d.  II.,  Hyperasthesia  and  Anasthesia." 
Zeitschrift.  d.  Ges.  d.  Aerzte  zu  Wien,  1850,  p.  542. 

^  Nothnagel  (H.).  "  Beitrag  zur  Pathologie  der  Neuralgien."  Virchow's 
Archiv.  Bd.  LIV.  1872.  p.  121;  and  "Diagnosis  and  Pathology  of  Neuritis," 
by  Prof.  H.  Nothnagel.  German  Clinical  Lectures  (Volkmann).  Syd.  Soc,  2nd 
series,  p.  215. 


124  ELEMENTARY  AFFECTIONS   OF 

present  is  to  describe  the  elementary  symptoms  separately.  The 
description  of  the  remaining  concomitant  symptoms  of  neuralgia 
is  deferred  for  the  present. 

(II.)-SENSORY  AFFECTIONS   OF   THE    VOLUNTARY   MUSCLES 
(MUSCULAR  ^STHESIONEUROSES). 

§  58.  Muscular  Sensibility  and  Muscular  Sense. — There  can 
be  no  doubt  that  certain  sensations  arise  during  muscular  activity, 
which  appear  to  be  quite  independent  of  the  cutaneous  sensibility. 
These  sensations  are  of  two  kinds :  the  first,  called  muscular 
sensibility,  corresponds  with  the  common  cutaneous  sensation, 
and  consists  of  the  pleasurable  and  painful  feelings  connected 
with  muscular  exercise ;  and  the  second,  called  Tnuscular  sense, 
corresponds  with  the  cutaneous  tactile  sensibility,  and  consists  of 
those  sensations  by  which  the  mind  is  enabled  to  discriminate 
differences  in  the  degree  of  contraction  of  the  muscles  ;  the  former 
being  an  emotional  and  the  latter  an  intellectual  sensation. 

(1)  Tests  for  Muscular  Sensibility. — The  state  of  muscular  sensibility  is 
best  tested  by  means  of  faradisation.  When  a  healthy  muscle  is  made  to 
act  a  dull  feeling  accompanies  the  contraction,  which  is  entirely  absent  if 
the  muscular  sensibility  is  abolished.  There  is  also  absence  of  sensitive- 
ness when  heavy  pressure  is  made  upon  the  muscles. 

(2)  Tests  for  Miiscular  Sense. — To  test  the  muscular  sense  the  patient 
should  be  made  to  lift  various  weights  and  to  form  an  estimate  of  their 
differences.  In  order  to  eliminate  the  cutaneous  sense  of  pressure  the 
weights  should  be  placed  in  a  cloth  and  suspended  from  the  limb  to  be 
tested,  or  they  may  be  held  in  the  fingers,  so  as  to  be  supported  rather 
by  friction  than  by  pressure.  The  sense  of  effort  may  be  tested  by  the 
dynamometer.  The  patient  may  also  be  made  to  move  the  limb  into 
certain  prescribed  positions  with  closed  eyes,  or  he  may  be  asked,  the  eyes 
being  still  kept  closed,  to  touch  a  particular  part  of  the  body,  such  as  the 
tip  of  the  nose  or  the  lobule  of  an  ear,  with  the  forefinger  of  one  hand,  or 
to  take  hold  of  a  ticking  watch  held  before  him  ;  or,  in  the  case  of  the  legs, 
to  describe  an  imaginary  circle  on  the  floor  with  the  big  toe  ;  all  these 
actions  will  be  either  not  accomplished  or  imperfectly  performed,  according 
as  the  muscular  sense  is  abolished  or  impaired. 

§  59.  Muscular  Hypercesthesia  and  Hyperalgesia  are  often 
met  with  in  diseased  conditions.  The  excessive  feeling  of  fatigue 
and  prostration,  which  occurs  on  slight  exertion  in  the  prodromal 
stage  of  acute  diseases,  is  probably  due  to  excessive  irritability 
of  the  nerves  of  common  muscular  sensibility ;  hence  this  con- 


INDIVIDUAL   SENSORY  MECHANISMS.  125 

dition  may  be  regarded  as  one  of  muscular  hyperalgesia.  The 
feeling  of  unrest  and  desire  for  constant  change  of  position,  which 
has  been  called  "the  fidgets,"  and  which  is  so  troublesome  to  ner- 
vous and  hysterical  patients,  is  due  to  muscular  hypersesthesia. 

In  spasmodic  wry  neck  and  other  spasmodic  affections,  as  well  as  in 
muscular  cramps,  the  hypersesthetic  condition  of  the  affected  muscles  is 
often  very  great,  and  gives  rise  to  intense  pain.  Painful  conditions  of 
the  muscles  are  called  myalgia  or  myodynia.  Myalgia  is  sometimes  due 
to  local  changes  in  the  muscle  itself,  while  at  other  times  it  is  of  nervous 
origin.  The  nervous  affection  is  most  frequently  met  with  in  the  muscles 
of  the  neck  and  of  the  lumbar  region ;  and  inasmuch  as  it  closely  corre- 
sponds to  cutaneous  neuralgia,  and  to  the  neuralgia  of  joints  or  arthralgia, 
it  might  well  be  called  m,uscvXar  neuralgia  or  myoneuralgia. 

§  60.  Muscular  Ancesthesia  is  by  no  means  an  uncommon 
affection.  The  common  sensibility  of  a  muscle,  as  tested  by  the 
faradic  current,  may  be  diminished  or  abolished,  while  the  elec- 
tro-muscular contractility  and  the  electro -cutaneous  sensibility 
remain  intact. 

Duchenne^  drew  attention  to  the  fact  that  electro-muscular  contractility 
may  be  unaffected  ;  while  both  electro-muscular  sensibility  and  voluntary 
power  are  abolished.  This  occurs  more  especially  in  hysterical  paralysis. 
In  other  cases  of  hysteria  voluntary  power  is  maintained,  while  electro- 
muscular  sensibility  is  abolished.  Loss  of  muscular  sensibility  may  occur 
while  the  muscular  sense  is  retained,  and  the  former  condition  may  be 
conveniently  termed  muscular  analgia. 

Anaesthesia  of  the  muscular  sense,  or  of  the  sense  of  muscular 
effort,  is  characterised  by  a  diminution  or  loss  of  the  capacity 
of  recognising  small  weights,  or  of  perceiving  differences  of 
weight  by  muscular  contraction.  If  the  muscles  are  completely 
paralysed,  no  test  of  the  muscular  sense  can  be  applied.  Loss 
of  the  muscular  sense  is  frequently  associated  with  absence  of 
the  feeling  of  equilibrium  of  the  body,  inability  to  determine, 
when  the  eyes  are  closed,  the  position  of  the  limbs,  or  the  extent 
of  any  movement  that  may  be  performed.  It  is,  however,  not 
easy  to  determine  how  far  these  functional  disturbances  are 
dependent  on  the  mere  loss  of  muscular  sense  ;  since  other  sen- 
sory impressions,  such  as  those  of  the  skin,  bones,  and  joints, 
participate  in  the  actions. 

'  L'Electrisat.  localisfe.    Third  edit.,  1872,  p.  336. 


126  ELEMENTARY   AEFECTIONS   OF 

(III.)- SENSORY   AFFECTIONS    OF    THE    JOINTS    AND    BONES 
(ARTICULAR   AND   OSSEOUS   ^STHESIONEUROSES). 

The  existence  of  sensory  nerves  in  the  bones  and  joints  has 
not  yet  been  determined  anatomically,  but  the  facts  of  pathology 
leave  no  room  for  doubt  that  such  nerves  exist.  The  sensibility 
of  the  bones  and  joints  is  apparently  only  very  slight  in  the 
normal  condition,  but  they  may  become  exquisitely  sensitive 
under  pathological  conditions.  The  normal  sensibility  of  the 
bones  and  joints  probably  plays  an  important  part  in  enabling 
us  to  determine  with  closed  eyes  our  attitudes  in  space  and  the 
position  of  our  limbs  after  passive  movements. 

§  61.  Osteoneuralgia — Arthroneuralgia. — Excessive  or  ab- 
normal sensations  occur  in  the  bones  and  joints,  usually  in  the 
form  of  pain,  and  when  the  pain  is  not  caused  by  recognisable 
anatomical  changes  in  those  parts,  the  condition  is  regarded  as 
neuralgia  of  the  bones  and  joints,  which  may  respectively  be 
called  osteoneuralgia  and  arthroneuralgia. 

Neuralgia  of  the  bones  and  joints  differs  from  cutaneous  neuralgia  in 
not  radiating  along  the  course  of  the  principal  branches  of  the  affected 
nerves.  Neuralgia  in  the  region  of  distribution  of  a  nerve-trunk,  such  as 
the  sciatic,  is  not  generally  associated  with  neuralgia  of  the  bones  and 
joints ;  while  conversely,  the  latter  kind  of  neuralgia  is  not  usually  associated 
with  neuralgia  in  the  region  of  distribution  of  the  neighbouring  cutaneous 
nerves.  It  is  evident,  therefore,  that  sensory  nerves  of  the  joints  and 
bones  do  not  belong  to  the  system  of  afferent  fibres  of  the  mixed  nerves, 
and  it  is  probable  that  they  reach  the  bones  along  with  the  sympathetic 
plexus  which  smrounds  the  vessels.  The  fact  that  neuralgia  of  the  joints 
is  frequently  associated  with  local  disturbances  of  the  circulation,  such  as 
redness,  heat,  and  oedema,  also  appears  to  ^vour  this  supposition.  But 
certain  cutaneous  neuralgias,  such  as  the  lightning  and  burning  pains  of 
locomotor  ataxia,  are  often  associated  with  neuralgic  pains  in  the  bones 
and  joints,  but  in  all  such  cases  the  irritation  which  is  the  source  of  the 
neuralgic  pains  is  situated  in  the  posterior  root  of  the  nerves,  and  in  their 
continuation  through  the  posterior  columns  to  reach  the  posterior  horns  of 
the  gi-ey  matter. 

§  62.  General  Symptoms  of  Arthroneuralgia. — Articular 
neuralgia  was  first  described  by  Brodie;^  its  essential  symptom 

'  Brodie  (B.).  "Observations  on  Diseases  of  the  Joints."  Third  edit.  London, 
]834;  and  collected  works,  by  C.  Hawkins,  1865,  p.  133. 


INDIVIDUAL   SENSORY  MECHANISMS.  127 

is  intense  pain  in  the  joint  and  surrounding  dense  structures, 
which  often  radiates  in  various  directions.  The  pain  occurs 
in  paroxysms  which  come  on  spontaneously,  and  which  are 
separated  by  intervals  of  complete,  or  comparative,  freedom 
from  pain.  The  quality  of  the  pain  offers  little  which  is 
characteristic.  At  times  it  is  described  as  tearing  or  shootiuo" 
through  the  joint  like  lightning  ;  at  other  times  as  a  boring 
or  stabbing  pain.  Various  other  abnormal  sensations  may  be 
felt  besides  the  pain,  such  as  a  sensation  of  heat  or  cold, 
numbness,  and  formication.  The  attack  of  arthralgia  is  fre- 
quently ushered  in  by  premonitory  symptoms,  consisting  of 
abnormal  sensations  in  the  skin.  Pressure,  as  a  rule,  increases 
the  pain ;  but,  as  occurs  in  cutaneous  neuralgia,  slight  and 
superficial  pressure  may  produce  intense  pain ;  while  deep,  con- 
tinuous, and  uniform  compression  produces  no  effect,  or  even 
relieves  the  pain.  The  pain  is  also  much  increased  when  the 
attention  of  the  patient  is  directed  to  it ;  and  on  the  other  hand 
it  is  diminished  under  the  influence  of  general  fatigue,  and  does 
not  prevent  the  patient  from  sleeping.  Painful  points  may  be 
obtained  about  the  affected  joint  on  pressure,  which  Esmarch^  and 
Berger^  have  endeavoured  to  determine  for  individual  joints. 
These  probably  correspond  to  the  points  where  small  branches 
of  sensory  nerves  pass  to  the  capsule  of  the  joint  along  with  the 
vessels.  Cutaneous  hypersesthesia  is  very  generally  present  in 
the  early  stages  of  the  affection  in  the  neighbourhood  of  the 
affected  joint;  while  a  diminution  of  the  sensibility  of  the  cor- 
responding portion  of  the  skin  may  be  present  in  cases  of  lono- 
standing.  Besides  the  local  periarticular  pressure  points,  other 
tender  spots  not  unfrequently  occur  in  the  course  of  the  affection 
as  over  neighbouring  nerve  trunks,  or  over  the  spines  of  the 
corresponding  vertebrae. 

In  many  cases  the  sensory  disturbances  are  associated  with 
motor,  vaso-motor,  and  trophic  affections.  The  motor  distur- 
bances consist  of  weakness  and  helplessness  in  the  use  of  the 
affected  joint,  owing  to  the  fear  of  inducing  a  paroxysm  of  pain  ; 
but  occasionally  spastic  contraction  of  the  muscles  surrounding 

'  Esmarch  (F.).    Ueber  Gelenkneurosen.     1872. 

^  Berger  (0.).  "Zur  Lehre  v.  d.  Gelenkneura'gien."  Berl.  klin.  Wochenschr. 
1873,  No3.  22-24. 


128  ELEMENTARY  AFFECTIONS   OF 

the  joint  occurs,  which  is  increased  by  all  attempts  to  move  the 
joint,  but  completely  disappears  under  chloroform.  Sometimes 
a  creaking  or  crepitating  noise  is  heard  when  the  joint  is  moved, 
the  cause  of  which  is  not  fully  ascertained.  When  a  definite 
group  of  the  muscles  round  the  joint,  as  the  extensors,  become 
contracted,  their  antagonists  may  undergo  a  certain  amount  of 
atrophy,  but  seldom  to  any  great  extent. 

Vaso-motor  disturbances,  consisting  of  redness,  heat,  and  in- 
creased secretion  of  sweat,  sometimes  occur  in  the  neighbour- 
hood of  the  affected  joint.  These  phenomena  may  appear  and 
disappear  very  rapidly ;  and  may,  like  the  paroxysms  of  pain, 
assume  an  intermittent  character,  at  times  of  regular  type,  the 
symptoms,  for  instance,  recurring  every  evening.  A  circum- 
scribed doughy  or  fluctuating  swelling  in  the  neighbourhood  of 
the  affected  joint,  associated  with  redness  and  increased  tem- 
perature, is  sometimes  observed,  which  was  compared  by  Brodie 
to  an  unusually  large  urticaria  wheal. 

Swelling  of  the  joint  from  serous  effusion  within  the  capsule 
may  take  place,  and  it  is  apt  to  be  regarded  as  of  inflammatory 
origin,  while  effusion  of  the  tissues  surrounding  the  joint  as  the 
result  of  irritating  applications  tends  still  further  to  obscure  the 
true  nature  of  the  affection. 

(IV.)-SE]SrSORY   AFFECTIONS   OF   THE    INTERNAL    ORGANS 
(VISCERAL    ^STHESIONEUROSES). 

Visceral  neuralgia  has  already  been  considered  generally, 
along  with  cutaneous  neuralgia,  but  various  other  forms  of  vis- 
ceral sensory  disturbances  remain  to  be  considered.  These  forms 
are  visceral  hypersesthesia,  paralgesia,  and  anaesthesia. 

§  63.  Visceral  Hyperalgesia  and  Paralgesia. — The  visceral 
hyperalgesias  and  paralgesise  depend  partly  upon  abnormal 
irritation  of  the  visceral  sensory  nerves,  or  upon  increased  irri- 
tability of  these  nerves.  These  sensations  belong  to  the  sphere 
of  common  sensations,  since  they  have  no  distinct  objective 
character ;  in  other  words,  they  are  related  to  the  feelings  and 
not  to  the  intellect.  The  most  usual  feelings  which  come  under 
this  category  are  titillation,  globus,  pyrosis,  bulimia,  polydipsia, 
abnormal  feeling  of  voluptuousness,  and  the  feeling  of  oppression. 


INDIVIDUAL   SENSORY  MECHANISMS.  129 

(1)  Titillation  is  a  sensation  which  is  induced  by  abnormal 
irritation  or  undue  irritability  of  the  nerve  ends  of  certain 
regions  of  the  respiratory  mucous  membrane,  and  corresponds 
with  pruritus  of  the  external  skin.  And  as  the  latter  leads  to 
an  irresistible  tendency  to  scratching,  so  the  former  leads  to  the 
reflex  respiratory  movements  which  produce  coughing.  The 
sensory  branches  of  the  vagus,  and  especially  the  superior 
laryngeal  branch,  are  those  which  are  irritated  during  coughing. 

(2)  Globus  is  a  sensation  in  which  the  patient  complains  that 
a  ball  ascends  from  the  epigastric  region  to  the  throat.  This 
sensation  is  either  one  of  the  symptoms  of  hysteria,  or  it  may 
constitute  an  epileptic  aura.  This  feeling  is  supposed  by  some 
to  depend  upon  spasm  of  the  oesophagus  and  pharynx,  and  it 
has  consequently  been  called  (Esophagismus.  This  explanation 
is,  however,  very  unsatisfactory. 

(3)  Pyrosis,  or  waterhrash,  is  a  painful  sensation  in  the 
epigastrium,  consisting  of  a  sense  of  burning,  generally  attended 
with  the  rising  of  a  quantity  of  clear  watery  fluid  into  the  mouth, 
which  may  be  tasteless  and  neutral,  or  sour  and  acid  in  reaction. 
An  attack  of  pyrosis  may  last  from  a  few  minutes  to  many 
hours,  with  alternating  remissions  and  exacerbations. 

(4)  Buliinia  is  a  feeling  of  hunger,  which  is  abnormal  in  its 
period  of  occurrence  or  in  its  intensity,  and  which  is  appeased 
only  for  a  short  time  by  taking  food.  In  many  cases  a  large 
quantity  of  food  must  be  taken  before  the  feeling  of  repletion  is 
reached ;  but  in  order  to  constitute  bulimia  it  is  necessary  that 
the  sensation  of  hunger  should  return  in  an  unusually  short 
time  after  it  has  been  satisfied.  At  times  a  small  quantity  of 
food  satisfies  the  feeling  of  hunger ;  but  if  the  latter  returns 
after  an  interval  of  one  or  two  hours,  this  constitutes  bulimia. 
It  must  be  assumed  that  in  bulimia  the  afferent  nerves,  irritation 
of  which  constitutes  the  feeling  of  hunger,  are  in  a  condition  of 
abnormal  irritability.  It  may  be  said  that  the  absolute  hunger 
minimum  is  in  such  cases  greatly  diminished,  just  as  the 
absolute  pain  minimum  is  in  cutaneous  neuralgia.  Bulimia  is 
frequently  of  central  origin,  and  often  occurs  in  hysterical  and 
neuropathic  subjects.  It  also  occurs  in  epileptoid  conditions,  in 
diabetes,  and  during  convalescence  from  exhausting  diseases,  and 
is  a  frequent  symptom  of  insanity. 

VOL.  I.  J 


130  ELEMENTARY  AFFECTIONS   OF 

(5)  Polydipsia  is  an  excessive  feeling  of  thirst,  and,  like 
bulimia,  it  must  be  regarded  as  a  hyperalgesia.  It  is  generally 
believed  to  be  due  to  increased  irritability  of  the  sensory 
branches  of  the  vagus ;  but  this  is  very  doubtful,  since  the 
sensory  branches  of  the  mucous  membrane  of  the  mouth  and 
throat,  including  branches  of  the  fifth  and  glosso-pharyngeal 
nerves  participate  in  the  sensation  of  thirst.  Polydipsia  is  a 
constant  symptom  of  polyuria  and  diabetes ;  and,  like  bulimia, 
it  comes  on  after  exhausting  diseases,  and  as  a  symptom  of 
hysteria. 

(6)  Excessive  Voluptuous  Feeling  was  ascribed  by  Romberg^ 
and  others  to  neuralgia  of  the  spermatic  plexus.  Voluptuous 
sensations  are  specially  frequent  in  the  female  sex,  but  they 
are  by  no  means  relatively  more  frequent  in  the  hysterical.  In 
the  narrated  cases  in  which  excessive  voluptuous  feelings  were 
observed  in  hysterical  subjects  these  were  associated  with  ex- 
cessive reflex  and  psychical  phenomena,  with  quickening  of  the 
respiration  and  pulse,  great  emotioual  disturbance,  and  even  loss 
of  consciousness  and  general  convulsions.  In  women  who  are 
not  hysterical  excessive  voluptuous  feelings  are  found  associated 
with  symptoms  of  nymphomania,  or  they  appear  as  precursors  of 
an  epileptic  attack.  In  a  large  number  of  cases  local  irritation 
of  the  external  genitals  is  the  cause ;  while  in  other  cases  the 
abnormal  sensations  appear  to  depend  upon  changes  in  the 
afferent  conducting  apparatus  of  the  genital  organs  in  its  course 
through  the  spinal  cord  or  brain.  It  is  very  difficult  to  classify 
the  cases  which  have  been  adduced  as  examples  of  increased 
voluptuous  feelings  in  men.  In  many  cases  this  symptom  is 
associated  with  frequent  but  incomplete  erections,  premature 
ejaculation  of  semen,  and  more  or  less  complete  impotency. 
Local  irritation  of  the  genitals  is  usually  the  cause  of  these 
abnormal  sensations,  but  at  times  the  cause  may  be  a  spinal 
disease,  as  tabes  dorsalis. 

(7)  Feeling  of  Oppression,  when  general,  arises  probably  from 
over  work  or  deficient  nourishment  of  the  nervous  system.  It  is 
described  by  the  patient  as  a  feeling  of  heaviness,  dulness,  and 
depression  of  spirits.     A  more  specific  form  of  oppression  occurs 

*  Romberg.  A  Manual  of  the  Nervous  Diseases  of  Man.  Syd.  Soc.  Transl., 
1853.    Vol.  I.,  p.  145. 


INDIVIDUAL  SENSORY   MECHANISMS.  131 

in  connection  with  cardiac  affections,  as  angina  pectoris.  A 
feeling  of  oppression  or  constriction  is  experienced  across  the 
chest,  as  if  it  were  being  forcibly  compressed,  and  it  is  attended 
by  a  sense  of  suffocation.  The  patient  also  suffers  from  an 
intense  feeling  of  impending  danger  or  threatened  death.  Peri- 
pheral irritation  of  either  the  cardiac,  solar,  or  mesenteric 
plexuses  may  probably  give  rise  to  this  feeling  at  times,  although 
it  is  more  commonly  met  with  in  connection  with  affections  in 
the  region  of  distribution  of  the  cardiac  plexus. 

§  64.  Visceral  Analgesia. — Very  little  is  known  with  respect 
to  visceral  analgesia.  The  normal  functions  of  the  viscera  are 
performed  without  much  sensibility;  although  visceral  sensations 
contribute  greatly  to  the  feeling  of  well-being  and  comfort.  It 
is  probable,  therefore,  that  diminution  of  visceral  sensations  con- 
tribute in  an  equal  degree  to  our  general  feeling  of  bodily 
discomfort.  It  is  difficult  to  apply  any  reliable  tests  to  deter- 
mine the  degree  of  visceral  sensibility.  The  degree  of  reflex 
irritability  of  the  sympathetic  has  been  proposed  as  a  test  of  the 
degree  of  its  sensory  irritability ;  but  this  test  is  liable  to 
two  manifest  objections.  In  the  first  place,  it  is  questionable 
whether  the  peristaltic  action  of  the  bowels  and  similar  move- 
ments are  really  of  a  reflex  nature,  and  are  not  due  to  irritation 
of  automatic  peripheral  ganglion  cells.  In  the  second  place, 
even  were  it  proved  that  the  movements  presided  over  by  the 
sympathetic  are  of  a  reflex  nature,  it  by  no  means  follows  that 
because  the  reflex  conduction  is  diminished  or  abolished  the 
conduction  through  the  afferent  sensory  fibres  is  also  affected. 
The  reflex  tonus  of  the  constrictor  muscle  of  the  urethra  may  be 
abolished,  giving  rise  to  incontinence  of  urine  in  the  absence  of 
any  affection  of  the  sensibility  of  the  bladder,  although  it  is  by 
means  of  the  afferent  nerves  of  the  bladder  that  the  reflex  tonus 
is  maintained.  On  the  other  hand,  anaesthesia  of  the  bladder 
may  occur  without  the  reflex  tonus  of  the  sphincter  of  the 
urethra  being  diminished,  and  it  may  even  be  increased  under 
such  circumstances.  Similar  relations  obtain  in  other  reflex 
phenomena,  as  in  erection,  and  the  secretion  and  ejaculation  of 
semen. 

(1)  Anaesthesia  of  Laryngeal  and  Bronchial  Branches  of  the 


132  ELEMENTARY  AFFECTIONS   OF 

« 

Vagus. — When  aneesthesia  occurs  in  the  territory  of  the  laryngeal 
and  bronchial  branches  of  the  vagus  the  normal  amount  of 
irritation  does  not  give  rise  to  the  feeling  of  titillation  or  to  the 
reflex  movements  of  coughing.  This  condition  may  assume  a 
very  grave  significance  when  catarrhal  secretions  cease  to  induce 
cough,  and  consequently  accumulate  so  as  to  cause  suffocation. 
In  such  cases  the  anaesthesia  appears  to  be  of  central  origin,  and 
it  is  often  both  a  result  and  a  cause  of  increasing  poisoning  by 
carbonic  acid.  In  some  cases  the  inspiration  is  abnormally  slow 
without  any  subjective  feeling  of  inspiratory  desire  being  excited. 
Such  cases  are  probably  due  to  a  certain  degree  of  anaesthesia  in 
the  region  of  distribution  of  the  vagus. 

(2)  Ancesthesia  in  the  territory  of  the  gastric  branches  of  the 
Vagus  gives  rise  to  2^olyphagia,  a  condition  in  which  an  unusual 
quantity  of  food  must  be  taken  before  the  feeling  of  hunger  is 
satisfied  ;  or  in  which  the  feeling  of  repletion  is  never  obtained, 
however  much  food  is  taken.  The  experiments  of  Brachet,^ 
Arnold,  and  others  have  proved  that,  on  section  of  the  vagi, 
animals  continue  to  eat  until  the  oesophagus  is  filled  with  food. 
Pathological  observations  also  confirm  this  conclusion.  Swan 
mentions  a  case  where  the  patient  could  not  experience  the  feel- 
ing of  repletion  after  eating  large  quantities  of  food,  and  where 
after  death  both  vagi  were  found  atrophied  and  disorganised. 
This  condition  often  appears  in  affections  of  central  origin,  as 
hysteria,  epilepsy,  and  various  forms  of  insanity. 

(3)  Ancesthesia  of  the  Sexual  feelings  is  most  frequently 
observed  in  the  female  sex.  Diminution  of  these  feelings  is 
more  frequent  in  hysterical  females  than  excess  of  voluptuous 
sensations  ;  and  this  is  not  unfrequently  associated  with  decided 
aversion  to  coitus.  Complete  absence  of  voluptuous  feelings 
is  probably  due  to  anaesthesia  of  the  vaginal  mucous  mem- 
brane ;  such  as  occurs  in  hysterical  females  in  association  with 
diffuse  or  circumscribed  cutaneous  anaesthesia.  Analogous  con- 
ditions are  observed  in  the  male  sex,  as  a  result  of  sexual 
excesses  and  onanism,  or  as  a  symptom  of  chronic  affections  of 
the  spinal  cord,  such  as  spinal  meningitis  and  tabes  dorsalis,  or 
at  times  in  the  absence  of  any  appreciable  cause.    In  these  cases 

'  See  Wundt  (Dr.  W.).  Lehrbuch  der  Physiologie  des  Menschen.  4  Aufl.  1878. 
S.  194. 


INDIVIDUAL  SENSORY  MECHANISMS.  133 

diminution  of  the  electric  sensibility  of  the  glans  penis  and  of 
the  external  genitals  may  be  detected.  The  power  of  erection 
and  the  secretion  of  semen  become  diminished  or  abolished  in 
consequence  of  the  diminution  of  the  reflex  irritability,  and 
these  conditions  have  respectively  been  designated  Impotency 
and  Aspermatism. 

(V.)-SENSORY  DISTURBANCES  OF  THE  SPECIAL  SENSES. 

The  consideration  of  this  subdivision  of  the  ^sthesioneuroses 
is  reserved  for  the  special  part  of  the  work. 


134 


CHAPTEE    V. 


II.— ELEMENTARY   AFFECTIONS    OF    INDIVIDUAL    MOTOR 
MECHANISMS    (KINESIONEUROSES). 

(I.)-MOTOE   DISTUEBANCES    OF    THE    STEIPED   MUSCLES 
(EXTEENAL   KINESIONEUROSES). 

The  striped  muscles  are  for  the  most  part  connected  with  the 
skeleton,  and  by  their  contractions  they  move  the  bones  to 
which  they  are  attached,  and  thus  constitute  the  active  agents 
in  locomotion  and  in  maintaining  the  various  attitudes  of  the 
body.  The  graceful  form  of  the  body  is  also  in  great  measure 
due  to  the  rounded  bellies  of  the  muscles,  which  help  to  fill  up 
the  space  which  lies  between  the  bones  and  the  skin  and  sub- 
cutaneous tissues. 

§  65.  Methods  of  Examining  the  Motor  Apparatus. 

In  subjecting  the  neuro-muscular  mechanism  of  external  relation  to  a 
methodical  examination,  we  must  attend  to  (I.)  the  form  of  the  body  during 
repose,  and  (II.)  the  attitudes  of  the  body  during  actual  or  attempted 
movements. 

(I.)  Form  of  the  Body  during  repose. — In  order  to  see  whether  there  is 
any  departure  from  the  physiological  contour  and  attitudes  of  the  body,  the 
patient  should  be  stripped,  and  the  whole  naked  body  subjected  to  a  minute 
and  careful  examination.  As  a  rule,  the  bulk  and  consistence  of  a  muscle, 
as  felt  through  the  skin,  may  be  taken  as  an  adequate  sign  of  the  degree  of 
its  nutrition,  and  the  degree  of  its  nutrition  as  an  evidence  of  its  motor 
power ;  and  consequently  an  examination  of  the  body  by  inspection  and 
palpation  affords  most  valuable  information  with  regard  to  the  motor 
apparatus.  If,  for  instance,  the  outer  surface  of  the  shoulder  is  seen  to  be 
flattened,  and  the  head  of  the  humeras  can  be  felt  immediately  underlying 
the  skin,  it  is  immediately  known  that  the  deltoid  is  wasted  ;  and  if  the 


AFFECTIONS  OF  INDIVIDUAL  MOTOR  MECHANISMS.         135 

opposite  shoulder  is  at  the  same  time  plump  and  rounded,  the  inference  is 
at  once  made  that  the  aflfected  deltoid  is  wasted  from  a  special  and  not  from 
a  general  cause.  The  degree  of  paralysis,  which  accompanies  this  wasting, 
can  then  be  readily  made  out.  If,  instead  of  being  wasted,  the  deltoid  is 
imduly  prominent  and  tense,  and  the  elbow  is  held  permanently  removed 
from  the  trunk,  it  is  at  once  apparent  that  the  muscle  is  the  subject  of  spasm. 
Permanent  distortion,  such  as  the  various  forms  of  club-foot,  the  fixed  atti- 
tudes of  hemiplegic  limbs,  and  spinal  curvatures,  may  be  readily  detected 
by  inspection,  aided  by  palpation  and  passive  movements.  The  perform- 
ance of  passive  movements  will  enable  us  to  judge  whether  the  muscles 
are  relaxed  or  tense,  or  whether  they  are  readily  thrown  into  a  state  of 
convulsive  tremor.  When  a  deformity  is  produced  by  spasm  or  paralysis 
of  a  deeply-seated  muscle,  it  is  not  always  easy  to  discriminate  the  par- 
ticular muscle  aifected.  In  the  case  of  spasm  valuable  information  may  be 
obtained  byproducing  a  corresponding  deformity  on  the  healthy  side,  or  in 
a  healthy  individual,  by  inducing  an  artificial  spasm  by  means  of  faradi- 
sation. Similar  information  may  be  obtained  in  the  case  of  paralysis  by 
inducing  an  artificial  spasm  of  the  antagonists  to  the  muscle  affected. 
It  is  scarcely  necessary  to  add  that  no  one  can  be  successful  in  examining 
the  motor  apparatus  unless  he  possess  an  accurate  knowledge  of  the  origin 
and  insertion  of  the  muscles,  as  well  as  of  their  functions. 

(II.)  Movements  of  the  Body. — Under  the  movements  of  the  body  we 
intend  to  include,  at  present,  all  contractions  of  the  muscles  of  external 
relation,  even  if  they  be  not  attended  by  manifest  changes  in  the  form  and 
attitudes  of  the  body.  These  muscles  may  be  excited  to  contraction  by  (1) 
voluntary,  (2)  automatic,  (3)  reflex,  (4)  mechanical,  and  (5)  electrical 
stimuli. 

(1)  Voluntary  Movements. — Much  valuable  information  may  be  obtained 
by  close  observation  of  a  subject  during  voluntary  movement  or  attempted 
movement.  The  student  should  make  a  careful  study  of  the  difierent 
forms  of  disordered  locomotion,  and  be  able  to  distinguish  at  a  glance  the 
hemiplegic  wallc,  the  spastic  gait,  and  the  loose  and  dangling  limbs  of  the 
various  forms  of  atrophic  paralysis.  The  patient  should  now  be  asked  to 
perform  special  movements,  as  running,  hopping,  standing  on  one  leg, 
ascending  a  stair,  writing,  speaking,  and  mimetic  facial  movements,  in 
■  order  that  any  deviation  from  the  normal  may  be  carefully  observed.  The 
patient  may  be  totally  unable  to  execute  a  particular  movement  either 
from  paralysis  of  the  muscles  which  ought  to  be  in  action,  or  from  spasm  of 
their  antagonists,  and  it  is  not  difficult,  as  a  rule,  to  decide  which  of  the  two 
is  the  cause.  When  the  paralysis  is  incomplete  it  becomes  important  to 
ascertain  the  degree  of  motor  impairment.  The  motor  power  of  certain 
groups  of  muscles  can  be  measured  by  means  of  the  various  forms  of 
dynamometer;  and  an  approximate  estimate  may  be  made  by  comparative 
testing  of  the  resistance  which  can  be  opposed  to  passive  movements.  It 
is  also  important  to  observe  whether  the  muscular  contraction  can  be 
maintained  for  some  time  without  inducing  exhaustion,  and  whether  the 


136  ELEMENTARY  AFFECTIONS   OF 

intended  movement  is  executed  witli  precision  and  steadiness  or  is  inter- 
rupted by  tremors  and  antagonistic  secondary  movements, 

(2)  Automatic  Movements. — The  movements  of  respiration  and  of  the 
ii'is,  and  the  actions  of  the  sphincters,  may  be  adduced  as  examples  of 
automatic  actions  which  ought  to  be  carefully  observed.  Even  in  ordinary 
station  and  locomotion  a  large  number  of  the  muscles  contracted  are  regu- 
lated by  an  automatic  mechanism,  and  the  physician  should  be  able  to  dis- 
tinguish at  a  glance  the  ataxic  walk,  the  cerebellar  reel,  the  staggering 
gait  of  Meniere's  disease,  and  the  uncertain  tremulous  walk  so  frequently 
observed  in  disseminated  sclerosis. 

(3)  Reflex  Movements. — The  reflex  movements  of  the  skin  and  accessible 
mucous  membranes  must  be  tested  by  tickling,  pricking,  pinching,  and 
faradic  excitation,  and  the  reflexes  of  the  special  senses  by  their  special 
excitants,  while  the  muscular  contractions  obtained  by  tapping  tendons, 
fasciae,  or  periosteum  must  be  carefully  examined. 

(4)  Mechanical  Stimuli. — When  a  muscle  is  removed  from  the  body  the 
irritabiUty  gradually  diminishes,  and  after  a  time  disappears  altogether. 
But  if  a  sharp  blow  be  struck  across  a  muscle  which  has  entered  into 
the  later  stages  of  exhaustion,  a  wheal  lasting  for  several  seconds  is 
developed.  From  this  wheal  small  waves  of  contraction  run  in  both  direc- 
tions towards  the  extremities  of  the  muscle,  and  this  form  of  muscular 
action  has  been  called  "  idio-muscular "  contraction,  because  it  may  be 
brought  out  when  ordinary  stimuli  have  ceased  to  produce  any  effect.  A 
moderately  strong  blow  over  almost  any  muscle  of  the  body,  under  normal 
conditions,  induces  a  contraction  of  the  fasciculus  struck,  especially  if  the 
blow  fall  near  the  point  of  entrance  of  the  motor  nerves.  These  contrac- 
tions occur  with  greater  readiness  in  the  pectoralis  major,  deltoid,  and  the 
extensor  muscles  of  the  forearm,  than  in  the  other  muscles  of  the  body ; 
and  in  exhausting  diseases,  such  as  phthisis,  the  slightest  tap  over  the 
pectoral  muscles  causes  a  circumscribed  tumour  due  to  local  contraction  of 
the  subjacent  muscle. 

(5)  Electrical  Stimuli  are  also  very  valuable  for  testing  reflex  irrita- 
bihty,  but  they  are  even  more  important  when  directly  applied  to 
the  investigation  of  the  motor  apparatus.  Two  kinds  of  electric  currents 
are  usually  employed  for  the  purposes  of  electrical  research — the  faradic, 
induced,  or  interrupted  current,  and  the  galvanic,  constant,  or  continuous 
current.  Faradic  currents  consist  of  a  series  of  isolated  cm-rents,  each  of 
momentary  duration,  and  of  very  rapid  development  and  dechne,  following 
each  other  in  qmck  succession  and  flowing  alternately  in  opposite  direc- 
tions. Galvanic  currents  run  in  the  same  direction  and  with  the  same 
intensity,  and  are  continuously  produced.  By  means  of  the  commutator, 
however,  the  current  can  be  interrupted  at  pleasure,  and  thus  closing  and 
opening  muscular  contractions  may  be  induced.  The  current  may  also  be 
rapidly  reversed  by  means  of  the  commutator,  a  change  which  induces  a 
very  powerful  contraction. 

(a)  Faradic  Excitability  or  Irritability  is  the  term  used  to  designate  the 


INDIVIDUAL  MOTOE  MECHANISMS.  137 

kind  and  strength  of  the  reactions  exhibited  by  muscles  under  the  influence 
of  the  faradic  current.  Muscular  contraction  may  be  induced  by  the  direct 
application  of  the  faradic  current  to  the  muscles  themselves,  or  indirectly 
through  excitation  of  the  motor  nerves.  For  the  purpose  of  testing  the 
faradic  excitability  the  current  obtained  from  the  secondary  coil  of  the 
ordinary  induction  apparatus  called  the  "  secondary  induced  current "  is 
generally  used,  although  the  current  from  the  primary  coil,  called  the 
"  primary  induced,  or  extra  current,"  may  also  be  employed. 

The  cathode  of  the  secondary  induced  current  is  usually  employed  as 
the  exciting  pole,  while  the  anode  may  be  placed  upon  some  indifferent  part 
of  the  body,  as  the  sternum,  or  patella.  Excitation  of  the  muscles  through 
the  accessible  motor  nerves  with  a  feeble  faradic  current  induces  a  minimum 
contraction  ;  whilst  on  the  strength  of  the  current  being  increased,  strong 
tetanic  contractions  ensue.  In  comparing  the  results  obtained  in  different 
parts  of  the  body,  it  is  of  importance  to  remember  that  in  health  the 
muscles  supplied  by  the  symmetrical  nerves  of  the  two  sides  of  the  body 
can  be  excited  to  minimum  contraction  by  the  same  strength  of  current, 
and  that  those  supplied  by  various  superficial  nerves,  such  as  the  upper 
branches  of  the  facial,  the  spinal  accessory,  ulnar,  and  peroneal  nerves,  can 
be  excited  to  minimum  contraction  by  currents  of  the  same  intensity. 
Any  considerable  deviation  from  these  conditions  must  be  regarded  as 
pathological. 

Direct  excitation  of  accessible  muscles  is  best  performed  when  the  poles 
are  applied  over  the  points  at  which  the  motor  nerves  enter  the  muscles, 
and  these  may  be  ascertained  by  reference  to  Ziemssen's  diagrams,  which 
are  reproduced  in  the  special  part  of  this  work. 

(b)  Galvanic  Excitability  is  a  term  used  to  express  the  reactions  obtained 
in  response  to  opening  and  closing  the  circuit  and  to  the  continuous  passage 
of  the  galvanic  current.  Either  the  positive  pole  or  anode,  or  the  negative 
pole  or  cathode  may  be  used  as  the  exciting  pole,  whilst  the  other  is 
applied  to  some  indifferent  part  of  the  body,  as  the  sternum. 

The  law  of  contraction  both  of  motor  nerves  and  muscles  rests  upon 
the  facts  that  the  cathode  produces  contraction  chiefly  on  closure  of  the 
current ;  the  anode  chiefly  on  opening  the  current ;  and  that  the  stimulus 
of  the  cathode  is  stronger  than  that  of  the  anode.  The  reactions  obtained 
with  different  strengths  of  current  may  be  deduced  from  these  fundamental 
facts.  With  a  weak  current  the  cathode  produces  simple  contraction  on 
closure  of  the  current,  while  there  is  no  reaction  from  the  anode ;  with  a 
current  of  medium  strength  the  cathode  produces  stronger  contraction  on 
closure  of  the  current,  but  no  opening  contraction ;  while  the  anode  causes 
feeble  contractions  both  when  the  current  is  closed  and  when  it  is  opened. 

With  a  strong  current  the  cathode  produces  on  closure  of  the  current  a 
tetanic  tonic  contraction,  and  a  feeble  contraction  on  opening  the  current ; 
while  the  anode  produces  lively  contraction  both  on  opening  and  closing 
the  current. 

The  law  of  contraction  may  be  expressed  by  the  following  formulse  : — 


138  ELEMENTAEY  AFFECTIONS   OF 

Let  An = anode,  Ca= cathode,  C  =  contraction,  c= feeble  contraction, 
0'= strong  contraction,  S  =  closure  of  current,  0= opening  of  current, 
Te= tetanic  contraction  ;  then — 

Weak  currents  produce  Ca  S  C  . 

Medium    „  „        Ca  S  C  ,  An  S  c  ,  An  0  c  . 

Strong       „  „        Ca  S  Te  ,  An  S  C  ,  An  0  C  ,  Ca  0  c  . 

In  diseased  conditions  deviations  from  the  normal  law  of  contraction 
may  occur  by  way  of  excess  or  diminution  of  the  excitability ;  or  by 
changes  in  the  quality  of  the  various  reactions.  These  quantitative  and 
qualitative  changes  will  be  subsequently  described. 

AKINESIS  OF  THE  MUSCLES  OF  EXTERNAL  EELATIOK 
By  akinesis  or  paralysis  of  the  muscles  of  external  relation  is 
understood  the  diminution  or  abolition  of  the  power  to  contract 
the  affected  muscles  by  voluntary  effort.  The  term  paresis  is 
used  to  denote  diminution  of  motor  power ;  some  authors'  have 
endeavoured  to  restrict  paralysis  to  its  complete  abolition,  but 
the  latter  term  will  be  employed  in  subsequent  pages  in  a 
generic  sense  as  embracing  both  conditions. 

§  66.  Classification. 

Paralyses  of  the  muscles  of  external  relation  present  many 
varieties,  and  these  are  susceptible  of  being  classified  in  various 
ways.  Many  forms  of  paralysis  may  be  classified  according  to 
the  part  of  the  neuro-muscular  apparatus  in  which  the  lesion  is 
situated.  This  constitutes  the  topographical  classification.  In 
some  varieties  of  paralysis,  however,  no  lesion  has  hitherto  been 
discovered  ;  these  cannot  be  divided  according  to  the  locality  of 
the  lesion,  but  they  may  be  arranged  according  to  their  exciting 
causes  and  the  conditions  under  which  they  are  produced.  This 
may  be  called  an  etiological  classification.  We  propose  to  com- 
bine these  two  kinds  of  classification  in  one  scheme.  Cases  of 
paralysis  may  also  be  divided  according  to  the  nature  of  the 
lesion ;  such  as,  inflammation,  syphilis,  rheumatism,  which  under- 
lies the  paralysis.     This  forms  the  pathological  classification. 

But  the  different  forms  of  paralysis  may  also  be  arranged 
according  to  the  distribution  and  extent  of  the  affection.  This 
constitutes  the  clinical  classification.  Closely  allied  to  the 
clinical,  is  the  physiological  classification,  in  which  the  different 
varieties  of  paralysis  are  divided  according  to  the  functional  dis- 


INDIVIDUAL  MOTOR  MECHANISMS.  139 

turbances  present;  the  latter  two  methods  have  this  much  in 
common,  that  tbey  are  both  dependent  upon  an  analysis  and 
comparison  of  the  symptoms  of  individual  cases. 

We  shall  now  proceed  to  arrange  the  various  forms  of  paralysis 
according  to — I.  the  topographical  and  etiological,  II.  the  patho- 
logical, III.  the  clinical,  and  IV.  the  physiological  classification. 

I.  The  Topographical  and  Etiological  Classification. — Para- 
lysis of  the  muscles  of  external  relation  may  be  divided  into 
(i.)  functional  and  (ii.)  organic  paralyses.  The  functional 
paralyses  must,  of  course,  be  classified  according  to  their  etiology. 
They  are  usually  divided  into  (1)  toxic,  (2)  post-febrile,  (3)  reflex, 
(4)  hysterical,  (5)  post-epileptic,  and  (6)  malarial.  Dr.  Kussell 
Reynolds  describes  a  paralysis  dependent  upon  an  idea,  but  this 
form  cannot  be  distinguished  from  hysterical  paralysis.  It  may 
be  mentioned  that  many  forms  of  paralysis  naturally  included  in 
this  list,  such  as  lead  paralysis,  are  now  found  to  depend  upon  or 
at  least  to  be  accompanied  by  decided  structural  changes. 

The  organic  paralyses  may  be  divided  into  (1)  those  caused 
by  primary  disease  of  the  muscles  or  myopathic  paralysis,  and 
(2)  those  caused  by  primary  disease  of  the  nervous  system  or 
neuropathic  paralysis. 

The  neuropathic  paralyses  may  be  subdivided  into  (1)  cerebral, 
(2)  spinal,  and  (3)  peripheral  paralyses,  according  as  the  lesion 
is  situated  in  the  brain,  spinal  cord,  or  peripheral  nerves  respec- 
tively. But  although  this  division  is  very  convenient,  a  much 
more  important  distinction  is  that  which  divides  them  into  (1) 
cerebrospinal  and  (2)  spino-peripheral  paralyses. 

In  the  cerebrospinal  variety  the  lesion  is  situated  either  in 
the  motor  centres  of  the  cortex  of  the  brain  or  in  the  pyramidal 
tract,  the  fibres  of  which  connect  these  centres  with  the  ganglion 
cells  of  the  anterior  grey  horns  of  the  spinal  cord  and  their 
homologues  in  the  medulla  oblongata,  pons,  and  crura  cerebri. 
In  the  spino-peripheral  variety  the  lesion  is  situated  in  the 
anterior  grey  horns  of  the  spinal  cord  and  their  upward  con- 
tinuations in  the  medulla  oblongata,  pons,  and  crura  cerebri,  or 
in  the  fibres  of  the  peripheral  nerves  which  connect  these 
ganglion  cells  with  the  muscles.  It  will  hereafter  be  found  that 
this  anatomical  division  corresponds  more  or  less  closely  with 
the  physiological  division  of  paralysis,  and  this  constitutes  its 


140  ELEMENTARY  AFFECTIONS   OF 

chief  advantage.  It  may  here  be  mentioned  that  when  the 
lesion  is  restricted  to  one  of  the  physiological  tracts  of  the  spinal 
cord  the  affection  is  called  a  system-disease,  and  when  several  of 
these  are  simultaneously  implicated  the  affection  is  called  a 
mixed  or  indiscriminate  disease. 

II.  The  Pathological  Classification. — The  different  forms  of 
paralysis  are  arranged  according  to  the  nature  of  the  lesion  into 
rheumatic,  syphilitic,  inflammatory,  and  other  forms  of  paralysis. 
This  classification  is  very  important  so  far  as  treatment  is  con- 
cerned, but  it  need  not  detain  us  longer  at  present. 

III.  The  Clinical  Classification. — Various  names  have  been 
given  to  paralysis,  according  to  its  distribution  and  extent.  The 
paralysis  is  sometimes  limited  to  a  single  muscle,  or  group  of 
muscles,  or  all  the  muscles  supplied  by  a  particular  nerve  or 
plexus  of  nerves  may  be  implicated  ;  but  when  all  the  muscles  of 
one  extremity  are  paralysed,  the  condition  is  called  monoplegia. 
In  other  cases  the  paralysis  affects  both  halves  of  the  body  sym- 
metrically, and  then  it  generally  begins  in  the  lower  extremities 
and  spreads  to  the  trunk  and  upper  extremities.  This  is  the  usual 
kind  of  paralysis  from  disease  of  the  spinal  cord,  and  is  termed 
paraplegia.  In  other  cases  the  paralysis  affects  the  lateral  half 
of  the  body,  implicating  the  face,  arm,  and  leg  of  the  same  side, 
and  it  is  then  termed  hemiplegia.  The  lesion  which  causes  this 
form  is  usually  situated  in  the  opposite  hemisphere  of  the  brain ; 
hemiplegia  of  spinal  origin  is  named  hemiparaplegia.  When 
both  upper  and  lower  extremities  on  both  sides  are  paralysed 
the  condition,  when  due  to  spinal  disease,  has  been  named  para- 
plegia cervicalis,  and  when  caused  by  cerebral  disease,  bilateral 
hemiplegia  or  panplegia.  When  the  ocular  or  facial  muscles 
on  one  side  and  the  limbs  on  the  opposite  side  are  paralysed  the 
condition  is  called  crossed  or  alternate  hemiplegia. 

lY.  Physiological  Classification. — A  much  more  important 
distinction  than  those  depending  upon  the  extent  and  distribution 
of  the  affection  is  that  which  divides  the  various  forms  of  paralysis 
into  (1)  atrophic,  and  (2)  spastic  or  spasmodic  paralysis.  This 
division  does  not  embrace  every  form  of  paralysis,  inasmuch  as 
in  some  paralytic  affections  the  muscles  neither  undergo  active 
wasting  nor  are  affected  by  spasm.  The  distinction  is,  neverthe- 
less, an  exceedingly  important  one,  and  ought  to  be  kept  in  view 


INDIVIDUAL   MOTOR  MECHANISMS.  141 

ia  the  clinical  examination  of  every  case  of  paralysis.  In 
atrophic  paralysis  the  wasting  of  the  muscle  is  sometimes 
masked  by  an  interstitial  growth  of  fibroid  and  fatty  tissue 
which  maintains  and  may  even  increase  the  volume  of  the 
muscle.  In  these  cases,  however,  the  muscular  fibres  themselves 
undergo  progressive  atrophy,  and  finally  disappear.  There  are 
many  signs  by  which  this  masked  or  pseudo-hypertrophic 
paralysis  may  be  recognised  from  true  hypertrophy,  but  these 
need  not  be  described  at  present.  The  atrophic  variety  em- 
braces some  forms  of  myopathic  paralysis,  but  when  the  affection 
is  of  neuropathic  origin  the  atrophic  disease  corresponds  with 
the  spino-peripheral  division  in  the  topographical  classification. 
The  spasmodic  variety  may  also  embrace  myopathic  affections, 
such  as  local  rheumatic  muscular  disease,  but  the  neuropathic 
spasmodic  paralyses  correspond  with  the  cerebro-spinal  paralyses 
of  the  topographical  classification. 

§  67.  Symptoms. — If  the  paralysis  be  incomplete  the  affected 
limbs  are  helpless  and  the  various  movements  are  feebly  exe- 
cuted ;  if  it  be  complete  they  hang  loose  and  motionless,  or 
are  held  in  fixed  positions  by  associated  spasm.  The  symptoms 
vary  greatly  according  as  the  paralysis  is  of  the  atrophic  or 
spasmodic  variety.  In  atrophic  paralysis  the  affected  muscles 
are  flaccid ;  they  undergo  progressive  and  sometimes  very 
rapid  wasting,  and  the  reflex  contractility  is  abolished. 
The  electrical  reactions  of  the  nerves  and  muscles  in  atrophic 
paralysis  are  exceedingly  important.  In  one  variety,  of  which 
infantile  paralysis  may  be  taken  as  the  type,  the  faradic  irri- 
tability of  the  nerves  and  muscles  becomes  rapidly  diminished 
and  soon  abolished  in  severe  cases,  while  the  galvanic  excitability 
manifests  quantitative  and  qualitative  changes  which  will  be 
immediately  described  under  the  name  of  "  the  reaction  of  de- 
generation." In  another  variety,  of  which  progressive  muscular 
atrophy  may  be  taken  as  the  type,  the  faradic  irritability  of  the 
nerves  and  muscles  only  becomes  diminished  very  gradually  and 
in  proportion  with  the  muscular  wasting,  and  so  long  as  a  fibre 
of  a  muscle  is  left  a  reaction  is  obtained.  The  galvanic 
excitability  does  not  as  a  rule  manifest  any  qualitative  changes. 
In  atrophic  paralysis  the  muscles  sometimes  exhibit  an  increased 


142  ELEMENTAEY  AFFECTIONS   OF 

excitability  to  mechanical  irritation.  The  affected  muscles  respond 
by  a  distinct,  slow,  and  protracted  contraction  to  mechanical 
stimuli,  such  as  tapping  with  the  tip  of  the  finger  or  a  blow  with 
a  light  percussion  hammer.  The  increased  mechanical  appears 
to  be  more  or  less  connected  with  the  increased  galvanic  excita- 
bility ;  but  the  augmentation  of  the  former  occurs  at  a  somewhat 
later  period  than  that  of  the  latter.  When  once  the  mechanical 
excitability  appears  it  increases  rapidly,  and  is  particularly  well 
marked  in  muscles  having  a  firm,  bony  support ;  it  then  gradually 
diminishes,  and  disappears  in  the  course  of  the  third  or  fourth 
month.  The  spinal  form  of  atrophic  paralysis  is,  as  a  rule, 
unaccompanied  by  sensory  disturbances  or  disorders  of  the  bladder 
and  rectum.  The  peripheral  variety,  on  the  other  hand,  is,  except 
when  the  disease  is  situated  in  a  purely  motor  nerve,  always 
accompanied  by  various  sensory  disturbances,  such  as  anaesthesia, 
hypersesthesia,  parajsthesia,  dyssesthesia,  and  severe  neuralgic 
pains,  as  well  as  with  various  cutaneous  vaso-motor  and  trophic 
disorders. 

In  the  spastic  or  spasmodic  variety  the  affected  muscles  are 
tense,  the  tension  is  increased  by  passive  movements,  and  the 
limbs  are  held  in  fixed  attitudes  or  are  agitated  by  clonic  spasms ; 
the  reflex  contractility,  especially  the  contraction  provoked  by 
tapping  the  tendon,  is  increased,  and  the  electrical  reactions  and 
mechanical  reflex  are  slightly  increased  or  normal.  In  the  cerebral 
variety  of  spasmodic  paralysis  the  affection  generally  assumes  the 
hemiplegic  form,  and  then  the  automatic  movements,  such  as 
those  of  respiration,  are  not  liable  to  be  much  affected.  The 
automatic  movements  of  the  iris  may  be  affected  if  the  lesion  be 
situated  in  the  crus  cerebri,  and  implicate  the  nucleus  of  origin 
of  the  third  nerve.  Sensory  disturbance  in  the  form  of  hemi- 
ansesthesia  may  or  may  not  be  present  according  to  the  situation 
of  the  lesion.  Associated  movements  may  be  preserved  in  the 
paralysed  parts,  but  these  will  be  subsequently  described  under 
the  name  of  synkinesis. 

When  the  spinal  variety  of  spasmodic  paralysis  constitutes  a 
system-disease  it  is  not  accompanied  by  sensory  or  trophic  dis- 
turbances, but  much  more  frequently  the  affection  is  a  mixed 
disease,  such  as  is  caused  by  a  transverse  myelitis.  In  the  latter 
case  the  affection  is  accompanied  by  various  sensory  vaso-motor 


INDIVIDUAL  MOTOK  MECHANISMS.  143 

and  tropliic  disturbances  as  well  as  by  disorders  of  the  functions 
of  the  bladder  and  rectum,  and  of  the  automatic  mechanisms 
of  respiration  and  of  the  iris. 

If  the  characteristics  of  atrophic  and  spasmodic  paralyses 
were  always  well  pronounced  there  would  be  no  difficulty 
in  distinguishing  one  from  the  other.  It  must,  however,  be 
remembered  that  in  the  minor  forms  of  the  atrophic  variety  the 
reaction  of  degeneration  may  not  become  established,  and  the 
wasting  may  not  be  very  perceptible ;  while  in  the  spasmodic 
variety  the  tension  does  not  appear  until  six  weeks  or  two 
months  after  the  onset  of  the  attack.  It  will  therefore  be  seen 
that  it  is  not  always  easy  to  determine  whether  the  paralysis 
belongs  to  the  atrophic  or  spasmodic  variety,  but  the  distinction 
is  so  important  that  it  should  never  be  lost  sight  of  in  conducting 
a  clinical  examination. 

In  the  annexed  tables  the  various  forms  of  paralyses  are 
arranged  according  to  the  methods  of  classification  just  described, 
and  they  will  be  found  none  the  less  useful  because  we  are 
obliged  to  anticipate  in  them  much  that  will  only  become 
apparent  during  the  progress  of  the  work. 

A  methodically  conducted  electrical  examination  of  the  nerves 
and  muscles  is  indispensable  in  distinguishing  between  the 
different  forms  of  paralysis,  and  in  forecasting  their  progress 
towards  recovery,  or  towards  permanent  and  irremediable  disease. 

§  68.  Electrical  Examination. — Although  Marshall  HalP  was 
the  first  to  direct  attention  to  the  value  of  an  electrical  exami- 
nation of  the  muscles  for  diagnosis  and  prognosis,  yet  we  are 
chiefly  indebted  for  our  accurate  knowledge  of  the  subject  to 
French  and  German  authors,  more  especially  to  Duchenne^  and 
Erb,^  and  it  is  from  the  writings  of  the  latter  author  that  the 
following  account  has  mainly  been  taken.  The  reactions  obtained 
may  be  subdivided  into  several  groups : — 

1.  The  First  Group  comprises  those  cases  where  both  nerves  and  muscles 
react  normally  to  faradic  and  galvanic  currents.    The  electrical  contractility 

'  Marshall  Hall.  "  Memoirs  on  some  Principles  of  Pathology  in  the  Nervous 
System."    Med.-Chir.  Transactions,  Vol.  XXII.,  1839,  p.  200. 

^  Ziemssen's  Cyclopsedia.     Vol.  XI.,  p.  423  et  seq, 

'  Handbuch  der  Elektrotherapie  von  Dr.  W.  Erb.    Leipzig,  1882. 


TABLE  I. 


NEUROPATHIC   PARALYSES. 


A.   OEGANIC   PARALYSES. 


I.  SPINO-NEURAL  OE  ATROPHIC  PARALYSES. 


(i.)  Neural  or  Peripheral  Paralysis. 

^1.  Acute  Atrophic  Spinal  Paralysis  of  Infants 

2.  Acute  Atrophic  Spinal  Paralysis  of  Adults. 

3.  Chronic  Atrophic  Spinal  Paralysis. 

4.  Peri-Ependymal  Myelitis. 

5.  Progressive  Muscular  Atrophy. 

6.  Exophthalmoplegia  Externa. 
*^  7.  Primary  Labio-G-losso-Laryngeal  Paralysis. 


(ll.)  SpinalAtrophicParalyses.  - 


II.  CEREBRO-SPINAL  OR  SPASMODIC  PARALYSES. 


r  1.  Primary  Lateral  Sclerosis. 
2.  Compound  Lateral  Sclerosis. 
..£,.,„  J-  T.      ,  "•  Amyotrophic  Lateral  Sclerosis, 

(r.)  SpmalSpasmodicParalyses.  ^  ^    Combined  Posterior  and  Lateral  Sclerosis. 

j  3.  Secondary  Lateral  Sclerosis. 

!  a.  Compression  Myelitis. 

L  6.  Transverse  Myelitis. 


(PARAFLEGI^.^ 


(li>)  Cerebral  Paralyses. 

(HEMIPLEGIA!.) 


1.  Tonic  Spasm,     j 


Tonic  &  Clonic 
Spasm. 


3.  Clonic  Spasm. 


a.  Early  Rigidity. 

b.  Late  Rigidity. 

a.  Intermittent  Tremor. 

b.  Choreiform  Movements. 

L  Prse-Hemiplegie  Chorea, 
ii.  Post-Hemiplegic  Chorea, 
iii.  Spastic  Hemiplegia  of  Infancy, 

a.  Continuous  or  Remittent  Tremors. 

b.  Athetosis. 

c.  Post-Hemiplegic  Hemiataxia. 


III.  MIXED  PARALYSES. 


B.  FUNCTIONAL  PARALYSES. 


(1)  Toxic  Paralysis. 

(2)  Post-febrile  Paralysis. 

(3)  Reflex  Paralysis. 

(4)  Hysterical  Paralysis. 

(5)  Post-Epileptic  Paralysis. 

(6)  Malarial  Paralysis. 


TABLE  II. 


PARALYSES    FROM    ORGANIC    DISEASE    OF   THE 
NERVOUS    SYSTEM. 


CLINICAL   DIAGNOSIS. 


I.  ATROPHIC  PARALYSES. 


(l.)   NEUBAL  or  PERIPHERAL  PARALYSES. 
(ll.)   SPINAL  ATROPHIC   PARALYSES. 


1.  Acute  Atrophic  Spinal  Paralysis 

of  Infants. 

2.  Acute  Atrophic  Spinal  Paralysis 

of  Adults. 

3.  Chronic  Atrophic  Spinal  Paralysis. 

4.  Peri-Ependymal  Myelitis. 

5.  Progressive  Muscular  Atrophy. 

6.  Exophthalmoplegia  Externa. 

7.  Primary  Labio-Glosso-Laryngeal 

Paralysis. 


II.  SPASMODIC   PARALYSES. 


(I.)   SPINAL   SPASMODIC  PARALYSES. 

1.  Primary  Spinal  Spasmodic  Paralysis. 

2.  Compound  Spinal  Spasmodic  Paralysis. 

3.  Secondary  Spinal  Spasmodic  Paralysis. 

(II.)  CEREBRAL  PARALYSES. 


1.  Ordinary  Hemiplegia. 

2.  Alternate  Hemiplegia. 

3.  Hemiplegia  and  Hemiansesthesia. 

4.  Hemiplegia,  Hemianassthesia  and 

Hemianopsia. 

5.  PrsB-Hemiplegic  Chorea. 

6.  Post-Hemiplegic  Chorea. 

7.  Athetosis. 

8.  Post-Hemiplegic  Continuous  Tremor 

and  Hemiataxia.y 

9.  Spastic  Hemiplegia  of  Infancy. 

10.  Unilateral  Convulsions  and  Hemiplegia. 

VOL.  L  K 


TOPOGRAPHICAL  DIAGNOSIS. 


L  SPINO-NEURAL  LESIONS. 


(l. )  LESIONS   OP  PERIPHERAL  NERVES. 

(ll. )  LESIONS  OF  ANTERIOR  GBEY  HORNS. 
(POLIOMTELOPATHIES.) 

Poliomyelitis  Anterior  Acuta  Infantium. 

Poliomyelitis  Anterior  Acuta  Adultorum. 

Poliomyelitis  Anterior  Chronica. 

Degeneration  of  the  Ganglion  Cells  of 
J  the  Anterior  Horns  of  the  Spinal 
1  Cord  and  Motor  Cells  of  the  Medulla 
[      Oblongata. 


II.  CEREBRO-SPINAL  LESIONS. 

(pyramidal  tract.) 


(l.)  LESIONS  OP  THE  LATERAL  COLUMNS. 

Primary  Lateral  Scler.osis. 
J  Amyotrophic  Lateral  Sclerosis. 
I  Combined  Posterior  and  Lateral  Sclerosis, 
j  Compression  Myelitis. 
\  Transverse  Myelitis. 

(II. )  LESIONS  OF  THE  CEREBRAL  PYRAMIDAL 
TRACT  AND  MOTOR  AREA  OP  CORTEX. 

f  Lesions  of  Lenticular  Nucleus. 
1  Area  of  Lenticulo-Striate  Artery. 

Lesions  of  Crura  and  Pons. 

Lesions  in  Area  of  Opto-Striate  Artery. 


Lesions  in  the  Area  of  the  Posterior 

External  Optic  Artery. 


( Unilateral  Atrophy  of  the  Motor  Area 
J  of  Cortex, 

i  Porencephalus. 
Lesions  of  Motor  Area  of  Cortex. 


146  ELEMENTARY  AFFECTIONS  OF 

is  as  a  rule  unaflfected  in  paralysis  of  cerebral  origin  and  in  many  forms  of 
spinal  paralysis,  as  primary  lateral  sclerosis  and  transverse  myelitis. 

2.  The  Second  Group  includes  the  cases  in  which  there  are  simple 
quantitative  changes  of  the  electrical  excitability,  manifested  either  by 
increase  or  diminution  of  the  normal  reaction. 

(a)  Simple  increase  of  the  electrical  excitability  may  be  manifested  in 
several  ways.  If  the  faradic  current  be  applied  to  the  nerves  and  muscles 
there  is  an  increase  of  the  amount  of  contraction  with  the  same  strength 
of  current,  or  there  is  an  increase  of  the  distance  of  the  secondary  coil 
at  which  minimum  contractions  are  produced.  If  the  galvanic  ciirrent  be 
employed,  a  cathodal  closing  powerful  contraction  (Ca  S  C)  occurs  with 
feeble  currents  ;  and  a  cathodal  closing  tetanus  (Ca  S  Te)  is  induced  when 
the  strength  of  the  current  is  slightly  augmented ;  and  an  anodal  opening 
contraction  (An  0  C)  is  caused  by  weak  currents.  A  cathodal  opening 
contraction  (Ca  0  C)  is  also  readily  established,  and  in  some  cases  an 
anodal  opening  tetanus  (An  0  Te)  may  be  induced. 

Increase  of  electrical  excitability  occurs  to  a  moderate  extent  in  certain 
forms  of  spasmodic  paralyses,  whether  of  cerebral  or  spinal  origin ;  it  is 
also  met  with  in  some  cases  of  tabes  dorsalis ;  and  may  even  occur  as  a 
transient  symptom  in  a  few  cases  of  peripheral  paralysis. 

(6)  Simple  diminution  of  electrical  excitability  is  mainly  manifested  by 
the  reactions  to  the  various  currents  being  the  reverse  of  what  they  were 
in  simple  increase  of  the  excitability.  When  the  faradic  current  is  apphed 
to  the  nerves  or  muscles  the  same  strength  of  stimulus  causes  a  weaker 
contraction  than  in  health,  or  there  is  a  diminution  of  the  distance  of  the 
secondary  coil  at  which  minimum  contractions  are  produced,  which  may  in 
some  cases  proceed  to  complete  extinction  of  faradic  contractility.  With 
galvanic  currents  cathodal  closing  tetanus  (Ca  S  Te)  first  disappears  and 
cannot  be  induced  by  any  ordinary  strength  of  current ;  anodal  closing  and 
opening  contraction  (An  S  C  and  An  O  C)  disappears  next,  and  by  and  by 
cathodal  closing  contraction  (Ca  S  C)  can  only  be  obtained  with  the  strongest 
currents,  and  ultimately  there  is  complete  loss  of  galvanic  excitability. 

Simple  diminution  of  the  galvanic  excitability  is  rare  in  cerebral 
paralysis,  but  occurs  in  the  later  stages  of  bulbar  paralysis  and  in  certain 
forms  of  spinal  and  peripheral  paralyses.  It  may  indeed  be  laid  down  as  a 
general  rule  that  whenever  the  nervous  lesion  is  such  as  to  give  rise  only 
to  simple  atrophy  of  the  paralysed  muscles,  there  is  simple  diminution  or 
extinction  of  the  electric  excitability,  imaccompanied  by  any  qualitative 
changes  in  the  reactions  obtained. 

3.  The  Third  Group  consists  of  what  Erb  has  proposed  to  call  the 
"  reaction  of  degeneration,"  and  includes  both  qualitative  and  quantitative 
alterations  of  electrical  excitability.  -  The  alterations  in  the  reactions  of 
the  nerves  and  muscles  do  not  run  a  parallel  course,  so  that  the  two  must 
be  separately  described. 

(a)  Reaction  of  the  Nerves. — The  alteration  in  the  reaction  of  the  nerve 
begins  on  the  second  or  third  day  after  the  attack  of  paralysis.     A  con- 


INDIVIDUAL   MOTOR  MECHANISMS,  147 

tinuous  uuiform  diminution  of  both  the  faradic  and  galvanic  excitability- 
is  observable  without  any  qualitative  change,  and  in  very  rare  cases  only 
is  it  preceded  by  shght  increase.  The  diminution  begins  in  the  part 
nearest  the  lesion,  and  extends  rajjidly  to  the  periphery.  At  the  end  of 
the  first,  or  in  the  course  of  the  second  week  (from  the  seventh  to  the 
twelfth  day)  the  excitability  wholly  disappears.  In  incurable  cases  the 
loss  of  the  excitability  is  permanent ;  but  if  repair  of  the  diseased  tissue 
takes  place,  the  excitability,  after  being  lost  for  a  variable  period,  is 
gradually  restored.  The  reactions  to  both  currents  appear  almost  simul- 
taneously, beginning  first  in  the  central  segments  of  the  nerve  and  spread- 
ing slowly  to  the  periphery.  The  reactions  at  first  obtained  are  very 
feeble,  but  they  gradually  increase  in  strength  as  repair  proceeds,  although 
remaining  a  long  time  below  the  normal  standard  even  after  the  restoration 
of  voluntary  power  appears  complete.  During  the  early  stages  of  regene- 
ration voluntary  movements  may  be  effected  through  the  paralysed  nerves 
at  a  time  when  they  give  no  reaction  to  the  electrical  stimulus,  the  duration 
of  this  period  being  from  a  few  days  to  several  weeks.  Erb,  however,  has 
found  that  when  voluntary  impulses  begin  to  be  conducted  through  the 
injured  nerves  the  electric  stimulus  will  also  induce  contraction  if  it  be 
apphed  above  instead  of  below  the  point  of  injury. 

(b)  Reaction  of  Affected  Muscles. — The  electric  reactions  of  the  paralysed 
muscles  are  much  more  complicated  than  those  of  the  degenerated  nerves, 
since  they  are  not  affected  in  the  same  manner  by  the  two  currents.  The 
reactions  obtained  by  the  faradic  are  simpler  than  those  obtained  by  the 
galvanic  current,  the  former  being  almost  entirely  similar  to  those 
obtained  by  the  application  of  the  current  to  the  degenerated  nerves. 
When  the  electrode  is  placed  over  the  paralysed  muscle  a  diminution 
of  the  excitability  is  observed  towards  the  end  of  the  first  week,  and 
there  is,  as  a  rule,  complete  extinction  of  it  towards  the  end  of  the  second 
week.  Feeble  contractions  may  be  obtained  by  electrical  acupuncture 
for  some  time  longer,  but  they  are  limited  to  the  fasciculi  directly  excited. 
When  the  case  is  incurable  the  faradic  contractility  of  the  muscle  becomes 
permanently  abolished,  but  reappears  along  with  the  recovery  of  voluntary 
power,  although  usually  somewhat  later  than  in  the  nerves.  As  recovery 
proceeds  the  faradic  excitability  increases  gradually  but  slowly,  and 
generally  remains  for  a  long  time  abnormally  low,  especially  if  the 
paralysis  has  been  of  long  duration. 

The  Oahanic  Excitability  falls  in  conformity  with  the  faradic  excita- 
bility during  the  first  week,  but  in  the  course  of  the  second  week  the 
former  is  remarkably  increased,  and  continues  to  increase  during  the 
following  few  weeks.  The  affected  muscles  now  respond  to  currents  much 
too  feeble  to  act  upon  healthy  muscles.  The  character  of  the  contractions 
is  also  changed,  and  instead  of  appearing  suddenly  and  being  of  short 
duration,  as  in  health,  they  now  develop  gradually  and  slowly,  are  pro- 
tracted in  duration,  and  readily  pass  into  tetanus  even  when  produced  by 
feeble  currents. 


148  ELEMENTARY  AFFECTIONS   OF 

The  Law  of  Muscular  Contraction  also  becomes  changed  along  with,  the 
increase  of  the  excitability.  There  is  a  gradual  increase  of  the  anodal 
closing  contraction,  so  that  it  soon  equals  or  exceeds  the  cathodal  closing 
contraction  (An  S  C  =  or  >  Ca  S  C).  The  cathodal  opening  contraction 
on  the  other  hand  increases  in  a  relatively  greater  degree  than  the  anodal 
opening  contraction ;  so  that  the  former  soon  equals  or  exceeds  the  latter 
(Ca  0  C=or  >  An  0  C) ;  hence  there  is  a  complete  inversion  of  the  normal 
formula  of  muscular  contraction.  Mr.  Harris,  recently  one  of  the  House 
Physicians  at  the  Manchester  Royal  Infirmary,  pointed  out  to  me  that,  in 
a  case  of  atrophic  paralysis  under  observation  in  which  the  aflfected  muscles 
reacted  more  readily  to  anodal  than  to  cathodal  closm-e  (An  S  C  >  Ca  S  C), 
the  normal  reactions  were  obtained  (Ca  S  C  >  An  S  C)  when  the  current 
was  passed  through  the  muscle  by  means  of  a  needle  inserted  in  it.  I 
have  obtained  similar  results  in  several  other  cases,  in  which  the  muscles 
afforded  the  typical  "  reaction  of  degeneration "  when  the  current  was 
employed  percutaneously,  but  I  shall  not  attempt  any  explanation  of  this 
fact.  When  the  "reaction  of  degeneration"  has  attained  a  high  degree  the 
opening  contractions  disappear,  and  remain  absent,  though  with  some 
variations  in  different  cases,  for  from  three  to  eight  weeks,  or  sometimes 
for  a  much  longer  period. 

After  a  variable  period  of  time  the  galvanic  excitability  undergoes 
gradual  diminution,  so  that  stronger  and  stronger  currents  are  required  to 
produce  contraction  ;  and  in  incurable  cases  an  extremely  feeble  anodal 
closing  contraction  is  usually  the  last  sign  of  the  disappearing  muscular 
irritabihty.  When,  on  the  other  hand,  regeneration  and  recovery  take 
place,  the  normal  mode  of  reaction  is  gradually  re-established.  The  gal- 
vanic excitability,  however,  remains  a  long  time  below  its  normal  degree, 
so  that  at  a  certain  period  during  recovery  from  paralysis  the  muscles 
may  present  a  great  diminution  of  galvanic  with  an  increased  faradic 
excitabihty. 

The  reason  of  the  different  reactions  to  the  faradic  and  galvanic 
currents  appears  to  be,  as  has  been  pointed  out  by  Neumann,  that  the 
paralysed  muscles  have  lost  the  power  of  responding  to  ciirrents  of  very 
short  duration  ;  and  since  the  faradic  current  is  made  up  of  successive 
shocks  of  momentary  duration,  the  muscles  do  not  respond  to  them. 

The  primary  diminution  of  the  electric  excitability  of  the  muscles  runs 
a  parallel  course  with  the  excitability  of  the  nerve  fibres,  and  probably 
depends  upon  the  degeneration  of  the  terminal  nerve  fibres  within  the 
muscle  itself.  The  increase  and  qualitative  changes  of  the  galvanic  ex- 
citabihty appear  during  the  second  week,  this  being  the  time  during  which 
the  muscular  substance  is  undergoing  histological  and  chemical  changes . 
The  subsequent  diminution  of  the  galvanic  excitabihty  corresponds  with 
the  atrophy  of  the  muscular  fibres  ;  and  the  gradual  return  to  the  normal 
excitabihty  with  the  regeneration  of  the  muscle  from  the  atrophy  and 
cirrhosis  which  it  had  undergone. 

Whenever,  therefore,  the  "  reaction  of  degeneration  "  presents  itself  it 


INDIVIDUAL  MOTOE  MECHANISMS.  149 

may  be  inferred  that  considerable  anatomical  changes  have  taken  place 
in  the  nerves  and  muscles,  the  exact  nature  of  which  may  be  deduced, 
with  some  degree  of  certainty,  from  the  stage  to  which  the  electrical 
changes  have  advanced.  These  nutritive  changes  will  be  described  under 
the  section  treating  of  the  trophoneuroses. 

The  reactions  obtained  by  the  direct  application  of  the  galvanic  current 
to  the  muscles  may  be  formulated  as  follow :  — 

Law  of  Normal  Contraction. 

Weak  currents Ca  S  C 

Medium  currents Ca  S  C  An  S  c  An  0  c 

Strong  currents    Ca  S  Te         An  S  C         An  0  C  Ca  0  c 

Quantitative  Changes  {simple  degeneration). 


Simple  Increase.  Simple  Decrease. 

Weak  currents Ca  S  C     An  0  C  '7  §  ^ 

Medium  currents... Ca  S  Te    An  0  C  Ca  O  C   |  | 

Strong  currents    ...CaSTe    An  O  Te  Ca  0  C  1  CaS  C  AnS  c  AnO  c|  Ca  S  c 

Quantitative  and  Qualitative  Changes — Reaction  of  Degeneration 
(Atrophic  Degeneration). 
Currents — 

Weak 1.  Stage  of  increase   Ca  S  C    An  S  Te    An  0  C    Ca  0  C 

Medium..  2.  Stage  of  gradual  decrease   ...  Ca  S  c     An  S  Te 
Strong   ...  3.  Final  stage  prior  to  abolition  An  S  c 

The  following  diagrams  {Figs.  8,  9,  10,  11),  borrowed  from  Erb,^  repre- 
sent graphically  the  general  relations  of  motor  power,  electrical  excitability, 
and  structural  changes  of  the  nerves  and  muscles  which  are  present  in  the 
different  stages  of  paralysis.  "  The  first  thick  vertical  line  or  ordinate," 
says  Erb,  "  indicates  in  all  the  drawings  the  attack  of  paralysis,  the 
sudden  cessation  of  motility  ((^@);  the  period  of  return  of  motility  is 
indicated  by  a  star  (  -Xr  ).  The  succeeding  ordinates  represent  intervals 
of  one  or  more  weeks,  dating  from  the  occurrence  of  the  attack.  The 
undulations  in  the  line  representing  the  galvanic  excitability  of  the 
muscle  indicate  its  qualitative  changes.  Fig.  8,  for  instance,  exhibits 
the  diminution  of  excitabiUty  that  occurs,  both  in  nerve  and  muscle, 
during  the  first  week ;  the  extinction  of  excitability  of  the  nerves  and  of 
the  faradic  excitability  of  the  muscle,  the  augmentation  and  qualitative 
change  in  the  galvanic  excitability  of  the  muscle  in  the  second  week  ;  and 
the  return  of  the  motility  in  the  sixth  week.  In  the  eighth  week  it  may 
be  seen  that  the  motility  is  restored  to  some  extent,  that  the  nerve  has 
recovered  its  faradic  and  galvanic  excitability,  and  that  there  is  an  increase 
and  qualitative  change  in  the  galvanic  excitability  of  the  muscle,  and  so 
on."     In  the  second  degree  of  the  reaction  of  degeneration  the  faradic  and 

'  Ziemssen's  Cyclopaedia.     Vol.  XI.,  p.  436, 


150 


ELEMENTARY  AFFECTIONS   OF 


galvanic  excitability  of  the  nerve  does  not  appear  until  the  thirtieth  week 
{Fig.  9) ;  while  in  the  third  degree  {Fig.  10)  the  excitabihty  of  the  nerve 
never  returns,  but  the  galvanic  excitability  of  the  muscle  only  becomes 
finally  abolished  after  a  prolonged  period,  in  some  cases  extending  over  a 
IDeriod  of  two  years. 

Fig.  8. 
KECOVEEY   RAPID. 


Atrophy  and 
Degeneration      Maltipli cation  of  Nuclei 
of  the  Nerve.      in  the  Muscular  Fibres.     Regeneration. 


Cirrhosis. 


Motility. 

I'laaiv. 

J  ^.  Farad. 

g  (■  GalT.  and 
t  i  Farad.  Ex- 
^  (  citability. 


Motility. 
■S  (GalT. 
[Farad. 

d  f  Galv.  ani 
I  J  Farad.  E 
jg  (  citabilit; 


Fig.  9. 
RECOVERY   SLOW. 


Degeneration    Atrophy,  etc. 
of  the  Nerve,      of  Muscles. 


Cirrhosis. 


Regeneration. 


4.       6.      10.     15.     20.     25.     30.     35.     40.     45.     50.     65.  Week 


il—l 


jIUbm 


Degeneration 
of  the  Nerve. 


Fig.  10. 

NO    RECOVERY. 

Atrophy, 
Multiplication  of  Nuclei,  Cin-hosis. 


Complete 
Disappearance. 


10.     20.     30.     40.     50.     60.     TO.     80.     90.     100.     Week. 


Motility. 


INDIVIDUAL  MOTOR  MECHANISMS. 


151 


Motility. 
■3  (Galv. 
g  (Farad. 

a5  I'Galv.  and 

1  i  Farad.  Ex. 

2  (  citability. 


Fig.  11. 

Atrophy  and 
Degeneration  of    Multiplication  of  Nuclei 
the  Nerve.  (?)       in  the  Muscular  Fibres. 


Regeneration. 


A  "partial  reaction  of  degeneration"  has  been  described  by  Erb^  i^iff- 
11)  in  which  the  faradic  and  galvanic  excitability  of  the  aflFected  nerve  is 
diminished,  but  not  abolished,  the  diminution  being  sometimes  only  to  a 
very  slight  degree.  The  faradic  excitabiUty  of  the  paralysed  muscles 
undergoes  a  diminution  corresponding  to  that  of  the  nerve,  but  the  gal- 
vanic excitabihty  of  the  muscles  manifests  the  quantitative  and  quahtative 
changes  which  are  so  characteristic  of  the  severer  forms  of  the  reaction  of 
degeneration. 

The  "reaction  of  degeneration"  occurs  in  all  paralyses  of  traumatic 
origin,  accompanied  by  complete  division  or  crushing  of  the  nerves,  in 
certain  paralyses  of  rheumatic  origin,  especially  in  facial  paralysis,  and  in 
paralysis  from  neuritis,  and  compression  of  the  nerves  from  tumours  and 
other  causes.  It  also  occurs  in  lead  paralysis  and  in  infantile  paralysis, 
and  in  that  which  supervenes  in  the  course  of  or  subsequent  to  acute 
diseases  affecting  the  grey  anterior  horns  of  the  spinal  cord.  The  partial 
form  of  this  reaction  has  been  met  with  in  cases  of  rheumatic  facial  paralysis, 
in  certain  forms  of  atrophic  spinal  paralysis,  and  in  peripheral  paralysis  of 
various  nerves.  In  all  these  cases  the  paralysis  has  been  comparatively 
slight,  and  motor  power  has  reappeared  about  the  fourth  week  from  the 
commencement. 


HYPERKINESES   OF   THE   MUSCLES   OF  EXTERNAL  RELATION. 

Hyperkinesis  of  the  voluntary  muscles  consists  of  abnormal 
muscular  contractions  called  spasms.  Muscular  spasms  consist 
of  contractions  which  are  disproportionate  to  the  degree  of 
external  stimulus,  or  which  arise  in  the  absence  of  external 
stimulation  as  the  result  of  pathological  irritation.  Spasmodic 
affections  may  be  divided  into  two  groups.     In  the  first  group, 

'Erb(W.).    Handbuchder  Elektrotherapie.    I.  Halfte.    Leipzig,  1882.  p.  198. 


152  ELEMENTARY  AFFECTIONS   OF 

or  clonic  spasms,  the  affected  muscles  are  in  a  state  of  rapidly 
alternating  contractions  and  relaxations;  while  in  the  second 
group,  or  tonic  spasms,  the  affected  muscles  are  maintained  in  a 
state  of  persistent  and  equable  contraction. 

§  69.  Clonic  Spasms. 

(1)  Tremor  is  the  mildest  form  of  clonic  spasm.  It  consists 
of  slight  contractions  of  particular  muscles  or  groups  of  muscles, 
by  means  of  which  a  peculiar  rhythmical  oscillation  of  the  limbs 
and  trunk  is  produced.  The  higher  degrees  of  tremor  consist  of 
contractions,  which  are  strong  enough  to  cause  manifest  trembling, 
or  even  distinct  quivering  of  the  limbs,  such  as  those  met  with 
in  paralysis  agitans.  Fibrillary  contractions  consist  of  alternate 
contractions  and  relaxations  of  individual  bundles  of  muscular 
fibres,  which  are  visible  as  wavy  oscillations  under  the  skin,  but 
do  not  give  rise  to  any  movement  of  the  limb. 

Varieties. — A  very  old  division  of  tremor  into  two  varieties 
has  been  revived  by  Charcot,*  Gubler,  and  others.  The  distinc- 
tion was  indeed  made  by  Galen,  and  special  attention  was 
directed  to  it  by  Van  Swieten.  In  the  one  variety  the  tremor 
persists  during  repose,  and  Van  Swieten  attributed  this  form  to 
irritation,  affecting  the  nervous  centres  in  an  intermittent  and 
rhythmical  manner.  He  regarded  it  as  a  convulsive  pheno- 
menon, and  called  it  tremor  coactus.  In  the  second  variety  the 
tremor  is  exclusively  shown  during  the  execution  of  voluntary 
movements,  and  Van  Swieten  regarded  it  as  a  paralytic  pheno- 
menon, and  called  it  tremor  a  debilitate.  There  can  be  no 
doubt  that  there  are  two  varieties  of  tremor,  the  one  persisting 
during  repose,  and  the  other  only  appearing  when  the  patient 
makes  a  voluntary  effort ;  but  whether  the  former  is  due  to 
pathological  irritation  and  the  latter  is  a  paralytic  phenomenon 
is  open  to  question. 

Tremor  is  a  symptom  of  various  diseases  of  the  nervous 
system.  It  appears  locally  as  a  symptom  of  neuritis,  and  more 
extensively  distributed  as  a  symptom  of  certain  central  diseases 
of  the  nervous  system,  as  disseminated  sclerosis,  and  paralysis 
agitans,  and  also  of  chronic  poisoning  by  alcohol,  opium,  lead,  or 

»  See  Charcot  on  Diseases  of  the  Nervous  System  {Syd.  Soc).  Lond.,  1877. 
p.  130. 


INDIVIDUAL   MOTOR  MECHANISMS,  153 

mercury.  It  may  sometimes  occur  as  an  independent  disease, 
then  it  constitutes  simple,  essential,  or  idiopathic  tremor. 
Simple  uncomplicated  tremor  occurs  generally  in  old  age,  but  it 
is  occasionally  met  with  in  young  persons.  Women  appear  to 
be  more  disposed  to  tremor  than  men,  and  it  may  occasionally 
occur  as  one  of  the  manifestations  of  hysteria.  It  occurs  also  as 
a  symptom  of  exhausting  diseases,  like  typhoid  fever,  and  may 
be  caused  by  great  bodily  and  mental  exertion,  excessive  venery, 
and  onanism,  while  the  rigor  which  ushers  in  acute  diseases  may 
likewise  be  regarded  as  a  kind  of  tremor, 

(2)  Convulsion. — The  next  variety  of  clonic  spasm  is  termed 
convulsion.  Convulsive  movements  consist  of  energetic  contrac- 
tions and  relaxations  of  particular  muscles  or  groups  of  muscles, 
causing  a  rapid  succession  of  vigorous  movements,  and  giving 
rise  to  twitchings  of  the  face,  startings  of  the  limbs,  and  move- 
ments of  the  head  and  body.  If  the  majority  of  the  muscles  of 
the  body  are  affected  with  alternating  contractions  and  relaxa- 
tions, so  that  extensive  and  irregular  movements  of  the  trunk 
and  limbs  are  produced,  the  condition  is  termed  general  convul- 
sions; these  form  the  most  prominent  feature  of  epilepsy, 
ursemia,  eclampsia,  and  hysterical  attacks. 

§  70.  Tonic  Spasms. 

(1)  Cramp  is  the  simplest  form  of  tonic  spasm,  and  consists 
of  a  persistent  painful  contraction  of  a  muscle,  or  of  a  group  of 
muscles.  Cramp  of  the  calf  of  the  leg  is  the  most  common 
variety  of  this  affection  when  it  is  limited  to  a  single  muscle. 
It  frequently  comes  on  during  sleep,  more  especially  after  the 
muscles  of  the  calf  have  been  strained  the  previous  day  by  pro- 
longed walking  or  by  dancing.  Very  painful  and  troublesome 
cramps  of  the  abdominal  muscles,  and  of  those  of  the  lower  ex- 
tremities occur  in  severe  cases  of  summer  diarrhoea ;  but  these 
cramps  assume  their  highest  severity  and  importance  in  Asiatic 
cholera.  It  is  doubtful  whether  the  cramps  of  cholera  are 
caused  by  reflex  irritation  or  by  nutritive  changes  in  the  muscles 
and  nerves  induced  by  the  disease. 

In  tetanus  the  majority  of  the  muscles  of  the  body  are 
affected  with  cramps  which  occur  in  paroxysms  of  longer  or 
shorter  duration. 


154  ELEMENTARY  AFFECTIONS   OF 

A  peculiar  modification  of  cramp  is  met  with  in  catalepsy. 
The  muscles  in  this  affection  are  in  a  condition  of  moderate 
contraction  ;  but  the  resistance  they  offer  may  be  readily  over- 
come by  passive  movements,  so  that  the  limbs  may  be  made  to 
assume  constrained  positions,  which  they  retain.  From  the 
manner  in  which  the  limbs  can  be  moulded  into  various  posi- 
tions, this  condition  has  been  called  flexihilitas  cerea. 

(2)  Muscular  tension  is  a  state  of  moderate  contraction  of 
K.  certain  muscles  or  groups  of  muscles,  which  occurs  when  they 

are  stretched  either  by  passive  movements  or  by  a  voluntary 
contraction  of  their  antagonists.  This  condition  is  always  asso- 
ciated with  a  certain  degree  of  loss  of  voluntary  power  over  the 
affected  muscles. 

(3)  Contracture  is  meant  to  express  any  persistent  shortening 
of  a  muscle,  whereby  its  points  of  origin  and  insertion  are  per- 
manently approximated.  Muscular  contractures  are  of  various 
kinds.  In  the  first  group  the  contracted  condition  is  due  to 
primary  changes  in  the  muscular  substance  itself,  hence  it  may 
be  called  myopathic  contracture.  The  muscular  changes  consist 
of  induration  of  the  connective  tissue,  accompanied  by  fatty  de- 
generation and  subsequent  atrophy  of  the  muscular  fibres.  The 
structural  changes  in  the  muscle  are  indeed  due  to  a  sub-acute 
inflammation  of  its  substance,  a  myositis  which  from  the  in- 
creased growth  and  subsequent  shrinking  of  the  connective 
tissue  may  be  called  muscular  cirrhosis,  from  its  analogy  with 
cirrhosis  of  the  liver.  This  process  may  result  from  direct  injury 
to  the  muscle,  or  from  acute  rheumatism,  syphilis,  lead  poison- 
ing, and  various  other  causes.  Another  form  of  permanent 
muscular  contraction  may  be  called  paralytic  or  secondary 
contracture.  When  a  certain  group  of  muscles  is  paralysed, 
their  antagonists  have  their  ends  approximated,  and  after  a 
time  they  become  accommodated  to  their  new  positions  and  be- 
come permanently  contracted.  In  the  distortions  which  result 
from  long-standing  disease  of  the  joints,  the  muscles  whose 
extremities  have  been  approximated  also  remain  persistently 
shortened. 

But  the  form  of  muscular  contraction  which  more  immediately 
concerns  us  at  present,  is  that  which  is  caused  directly  by  ab- 
normal innervation,  and  which  may  therefore  be  called  primary 


INDIVIDUAL   MOTOR  MECHANISMS.  155 

neuropathic  contracture.  The  muscles  in  this  as  in  the  other 
forms  of  contracture  become  persistently  rigid  and  shortened, 
and  thus  give  rise  to  various  deformities.  It  is  always  asso- 
ciated with  a  certain  amount  of  paralysis.  The  rigidity  of  the 
muscles  usually  disappears  duriog  sleep  and  gradually  returns 
on  awakening,  and  it  is  almost  always  increased  by  voluntary 
and  passive  movements. 

§  71.  Concomitant  Symptoms. — Spasms  are  either  accom- 
panied or  followed  by  various  other  phenomena,  which  deserve 
mention.  Other  motor  disturbances  are  frequently  present, 
generally  in  the  form  of  diminution  or  loss  of  voluntary  power 
over  the  affected  muscles.  During  the  height  of  a  convulsion 
associated  movements  sometimes  occur  in  more  or  less  numerous 
groups  of  muscles,  in  consequence  of  irradiation  of  the  irritation 
into  the  various  intercommunicating  paths. 

Sensory  disturbances  are  frequently  associated  with  spas- 
modic affections.  A  sensation  of  fatigue  and  exhaustion  is 
often  felt  in  the  muscles  after  the  cessation  of  the  cramps ;  the 
muscles  also  feel  sore  and  tender  to  pressure  just  as  occurs  in 
healthy  muscles  subjected  to  undue  strain.  Pain  is  often  present 
in  the  contracted  muscles ;  while  spasm  due  to  an  affection  of 
a  mixed  nerve  is  frequently  accompanied  by  severe  neuralgic 
and  eccentric  pains,  formication,  numbness,  or  well  marked 
ansesthesia. 

Vaso-motor  and  secretory  disturbances  are  frequently  wanting, 
but  occasionally  localised  paleness,  redness,  or  cyanosis  of  the 
surface  is  observed.  Profuse  perspirations  occur  both  in  epilepsy 
and  tetanus,  and  sweating  on  one  side  of  the  body  has  been 
observed  in  unilateral  epilepsy;  and  after  severe  attacks  of 
convulsions  there  is  frequently  an  abundant  flow  of  clear  limpid 
urine  (urina  spastica). 

The  trophic  disturbances  are  usually  insignificant,  and  muscles 
affected  with  the  severest  spasms  do  not  necessarily  undergo 
either  hypertrophy  or  atrophy. 

Psychical  disturbances  are  not  unfrequently  associated  with 
spasms,  more  especially  in  epilepsy  and  hysteria.  It  is  very 
remarkable  how  little  the  general  health  suffers  from  severe 
spasmodic  affections. 


156  ELEMENTARY  AFFECTIONS   OF 

§  72.  The  Consecutive  Symptorjis  or  Sequelce  of  spasm  are 
for  the  most  part  mechanical,  and  result  from  the  undue  mus- 
cular contraction.  The  most  important  of  these  are  impairment 
of  the  mobility  of  joints,  abnormal  positions  of  the  head  and 
limbs,  curvatures  of  the  spinal  column,  alterations  of  the  arti- 
cular extremities  of  the  bones,  displacements  and  sub-luxations 
of  the  joints,  and  disorders  of  special  functions,  such  as  those  of 
the  respiratory  and  urinary  organs. 

The  state  of  the  electrical  contractility  of  the  affected  muscles 
and  nerves  varies  greatly,  being  often  normal,  and  at  other  times 
slightly  diminished  or  increased. 

§  73.  Pressure  Points  are  frequently  observed  in  spasmodic 
affections.  Pressure  upon  certain  points  puts  a  stop  at  times 
to  the  convulsion  when  present,  and  consequently  these  points 
may  be  called  motor  arresting  pressure  points  ;^  whilst  in  other 
cases  the  convulsions  are  brought  on  by  pressure  made  on  parti- 
cular points ;  hence  these  may  be  called  motor  exciting  pressure 
points.^  Pressure  points  of  the  first  kind  have  been  particularly 
observed  in  the  case  of  facial  spasm ;  and  they  correspond,  like 
the  painful  points  in  neuralgia,  to  the  various  branches  of  the 
trigeminus,  and  are  not  unfrequently  sensitive  to  pressure. 
Similar  pressure  points  have  also  been  observed  in  other  forms 
of  convulsion  than  those  affecting  the  face. 

§  74.  Theory  of  HyperJdnesis. 

Schiflf  3  was  the  first  to  observe  that  tremor  is  frequently  seen  in  muscles 
which  are  severed  from  their  connections  with  the  voluntary  nervous 
centres.  This  phenomenon  is  best  seen  in  the  muscles  of  the  tongue  of  the 
dog  after  section  of  the  hypoglossus.  Vibratory  movements  of  the  bundles 
of  muscular  fibres  may  be  seen  through  the  mucous  membrane  ;  and  when 
one  only  of  the  nerves  has  been  cut,  the  tremor  is  confined  to  the  paralysed 
side.  The  tongue  is  not  moved  as  a  whole  by  these  contractions.  A  few 
bundles  enter  into  contraction  at  a  time,  and  when  these  relax  other  bundles 

'  Graefe  (V.).  Arch.  F.  Ophthal.  Bd.  IX.  2,  p.  73;  and  Berl.  klin.  Wochenschr. 
1864,  pp.  43  and  206. 

Remak.  "Ueber  GesicMsmuskelkrampf."  Berl.  klin.  Wochenschr.  1864,  pp. 
209  and  229.    Ibid.  1865,  p.  280. 

'^  Hitzig.  "  Ueber  Eeflexerregende  Druckpunkte."  Berl.  klin.  Wochenschr. 
1866,  p.  69. 

*  Schiff.    Lehrbuch  der  Physiologie.    Bd.  I.,  1858-9,  p.  177. 


INDIVIDUAL   MOTOR  MECHANISMS.  157 

contract,  and  thus  the  organ  is  maintained  in  a  constant  state  of  tremor. 
In  rabbits  there  is  continual  oscillation  of  the  whiskers  after  section  of 
the  facial  nerve ;  and  in  birds,  trembling  of  the  iris  after  section  of  the 
motor  oculi.  Similar  trembling  occurs  in  the  muscles  of  the  extremities 
when  their  nerves  have  been  separated  from  the  spinal  centres.  The 
trembling  does  not  begin  until  some  days  after  section  of  the  nerves, 
and  it  gradually  reaches  its  maximum  towards  the  end  of  the  first  week, 
and  may  then  continue  months  or  even  years.  During  this  time  the 
peripheral  portion  of  the  nerve  is  undergoing  centrifugal  degeneration ; 
and  as  this  degeneration  induces  consecutive  changes  in  the  muscles,  it  is 
very  probable  that  the  tremor  is  a  symptom  of  the  structural  alteration 
which  the  muscles  are  undergoing,  or  that  it  is  due  to  pathological  irrita- 
tion of  the  motor  terminal  plates  in  the  interior  of  the  muscles.  Trembling 
is  a  marked  symptom  not  only  of  affections  of  the  peripheral  nerves,  but 
also  of  diseases  of  the  pyramidal  tract ;  in  one  word,  it  occurs  whenever 
the  influence  of  the  voluntary  centres  over  the  muscles  is  greatly  weakened 
or  abolished,  and  consequently  the  opinion  of  Eomberg^  that  tremor  may 
be  said  to  form  "  the  bridge  which  conducts  from  the  region  of  conrulsions 
to  the  paralyses"  is  not  without  justification.  A  tonic  spasm  of  a  muscle 
is  caused  by  the  fusion  of  rapidly  recurring  individual  spasms  into  an 
apparently  smooth  continuous  contraction.  When  the  resistance  to  con- 
duction is  greatly  increased  the  successive  nervous  shocks  do  not  recur 
with  sufficient  rapidity  to  produce  a  continuous  contraction,  but  a  series  of 
alternating  contractions  and  relaxations  occur,  which  is  the  essential  con- 
dition underlying  tremor. 

Another  theory  of  the  nature  of  tremor  has  also  found  acceptance  with 
some  modern  pathologists.  The  various  muscular  adjustments  of  the  body 
are  regulated,  as  already  stated,  both  by  the  cerebellum  and  cerebrum ; 
the  former  presiding  over  the  tonic,  and  the  latter  over  the  clonic  muscular 
contractions.  In  conformity  with  this  theory,  tremor  results  from  a  loss 
of  balance  between  the  actions  of  the  two  great  centres  of  innervation, 
being  more  especially  due  to  the  tonic  action  of  the  cerebellum  when  the 
action  of  the  cerebrum  is  enfeebled  (Jackson).  Contracture,  again,  is 
supposed  to  be  caused  by  the  complete  abolition  of  the  cerebral  influence, 
the  action  of  the  cerebellum  being  still  maintained  in  a  normal  condition. 
Reflex  spasms  are  caused  by  irritation  of,  or  excess  of  irritability  of  the 
reflex  arc  in  any  part  of  its  course,  either  of  the  afferent  or  efferent  fibres, 
or  of rthe  grey  substance  of  the  spinal  cord  itself. 

The  theory  of  general  convulsions  cannot  be  satisfactorily  discussed  at 
present.  Schroder  Van  der  Kolk  first  suggested  that  general  convulsions 
were  due  to  irritation  of  the  upper  portion  of  the  medulla  oblongata ; 
and   NothnageP   has   shown   that   they  may  be   induced   by  irritation 

1  Romberg.  A  Manual  of  the  Nervous  Diseases  of  Man.  Syd.  Soc.  Transl. 
1852,  Vol.  II.,  p.  230. 

*  Nothnagel.  "  Die  Entstehung  allgemeiner  Convulsionen  vom  Pons  und  von 
der  Medulla  oblongata  aus."     Virchow's  Arcliiv.     Bd.  XLIV.,  1868,  p.  1. 


158  ELEMENTARY  AFFECTIONS   OF 

of  a  limited  portion  of  the  floor  of  the  fourth  ventricle,  which  he  has 
consequently  named  the  convulsive  centre.  Various  experimental  and 
pathological  facts,  however,  favour  the  idea  that  general  convulsions, 
accompanied  by  unconsciousness,  are  determined  by  a  discharge  from  the 
cortex  of  the  brain.  The  cortical  discharge  may,  of  course,  be  induced  not 
only  directly  by  local  irritation,  but  also  indirectly  by  irritation  of  any 
portion  of  the  centripetal  apparatus.  Dr.  Hughhngs  Jackson,  who  was  the 
first  to  enunciate  this  theory,  also  thinks  that  the  tonic  contractions  of 
tetanus  are  caused  by  a  nervous  discharge  from  the  cortex  of  the 
cerebellum. 

ELEMENTARY  AFFECTIONS    OF   THE    REFLEX  MECHANISM  OF 
THE  MUSCLES  OF  EXTERNAL  RELATION. 

The  disturbances  which  occur  in  the  reflex  mechanism  situated 
in  different  parts  of  the  nervous  system  are  almost  infinitely 
numerous.  A  very  considerable  number  of  the  spasmodic  affec- 
tions already  described  belong  to  this  category,  and  in  most 
forms  of  paralysis  reflex  action  is  decidedly  implicated ;  while 
the  reflex  disorders  of  the  vaso-motor  mechanisms,  which  will  be 
subsequently  described,  are  exceedingly  important  and  diversified 
in  character.  It  will,  however,  be  useful  to  mention  here  a  few 
of  the  disturbances  which  occur  in  the  more  common  and  simple 
reflexes  of  the  spinal  cord.  The  reflex  system  of  the  spinal  cord 
consists  of  a  series  of  nerve  loops,  the  afferent  portions  of  which 
pass  in  through  the  posterior  roots  of  the  nerves,  and  become 
connected,  through  a  mechanism  of  cells  and  fibres,  with  an 
efferent  fibre  or  fibres,  which  pass  out  with  the  anterior  roots  of 
the  nerves,  to  be  conducted  to  the  muscles. 

Time  Required  for  Reflex  Actions. — In  a  reflex  act  an  impression  is 
made  upon  afferent  fibres,  which  convey  the  impulses  to  the  spinal  cord, 
where  they  are  reflected  through  efferent  fibres  to  a  muscle  or  muscles. 
Such  a  process  as  this  requires  an  interval  of  time  to  elapse  between  its 
initiation  and  completion,  and  the  period  which  intervenes  between  the 
application  of  the  stimulus  and  the  beginning  of  the  contraction  which 
ensues  is  called  the  latent  period.  The  length  of  this  latent  period  is 
readily  calculated  theoretically,  although  considerable  practical  difficulties 
may  present  themselves.     This  period  is  made  up  of  three  intervals  : — 

1.  The  first  interval  is  occupied  in  conducting  impulses  along  afferent 
and  efferent  fibres. — Conduction  through  a  metre  in  length  of  a  nerve  takes 
place  in  "03  of  a  second ;  and  if  x  be  equal  to  the  conjoined  length,  in 
metres,  of  the  afferent  and  efferent  fibres,  engaged  in  a  reflex  act,  the  time 
occupied  by  conduction  through  them  will  be  equal  to  "03^. 


INDIVIDUAL  MOTOR  MECHANISMS.  159 

2.  The  second  interval  consists  of  the  time  consumed  in  the  central 
operations  of  the  reflex  act,  and  the  length  of  which  Exner^  has  estimated 
at  '055  of  a  second. 

3.  The  third  portion  of  the  interval  consists  of  the  time  occupied  in 
setting  up  molecular  changes  in  the  muscle,  unaccompanied  by  any  visible 
alteration  in  its  form,  this  period  occupying  on  an  average  about  '01  of  a 
second. 

By  adding  the  estimated  lengths  of  these  three  portions  of  time  to- 
gether, we  obtain  the  length  of  the  interval  which  elapses  between  the 
application  of  a  stimulus  and  the  occurrence  of  the  resulting  reflex  con- 
traction, the  formula  being  •03.r+  '055 -|-  '01.  It  ought  to  be  remembered, 
however,  that  the  time  for  any  reflex  act  varies  greatly  within  healthy 
limits,  according  to  the  strength  of  the  stimulus  employed,  and  according 
as  the  nutrition  of  the  cord  and  nerves,  and  indeed  of  the  cephalic  ganglia, 
is  active  or  in  an  exhausted  condition.  When  once  the  miiscular  contrac- 
tion begins,  the  shortening  of  the  muscle  up  to  a  maximum  occupies  about 
"04,  and  its  return  to  its  former  length  "05  of  a  second. 

§  75.  Disease  of  the  reflex  mechanism  may  declare  itself  by 
way  of  excessive  reaction,  constituting  reflex  hyperkinesis,  or  by 
diminution  or  loss  of  reaction,  constituting  reflex  akinesis. 

Reflex  Hyperkinesis  is  caused  by  diseases  which  increase  the 
irritability  and  consequently  diminish  the  specific  resistance  of 
the  reflex  arc  in  any  part  of  its  course ;  those  which  arrest 
conduction  through  the  fibres  of  the  pyramidal  tract ;  and 
those  which  increase  the  irritability  of  the  muscular  fibres 
themselves. 

Reflex  Akinesis,  on  the  other  hand,  is  caused  by  diseases 
which  diminish  or  abolish  the  irritability,  and  consequently 
increase  the  specific  resistance  of  the  reflex  arc  in  any  part  of 
its  course ;  those  which  increase  the  cerebro-spinal  discharges 
passing  through  the  pyramidal  tract ;  and  those  which  diminish 
or  abolish  the  irritability  of  the  muscular  fibres  themselves. 

Localisation  of  the  Lesion. — The  irritability  of  the  reflex  arc 
may  be  increased,  diminished,  or  abolished  by  disease  affecting — 

(1)  The  afferent  fibres  of  the  arc  from  their  peripheral  origin 
until  they  pass  through  the  posterior  roots  of  the  nerves  {Fig. 
13,  p)  to  end  in  the  grey  substance  of  the  posterior  horns. 
When  either  the  afferent  fibres  or  their  peripheral  or  central 

>Exner(Dr  S.).  "  Experimeritelle  Untersiichung  der  einfachsten  psychischen 
Processe."    Pfluger's  Archiv.,  Bd.  VIII.,  s.  526. 


160  ELEMENTARY  AFFECTIONS   OF 

terminations    are    affected,    the    reflex    symptoms    are    usually 
accompanied  by  sensory  phenomena, 

(2)  The  efferent  fibres  of  the  reflex  arc,  at  their  central  origin 
in  the  ganglion  cells  of  the  anterior  horns,  in  their  passage 
through  the  anterior  root  zones,  anterior  roots  {Fig.  13,  a  a),  and 
peripheral  nerves;  and  finally,  in  their  peripheral  terminations 
in  the  individual  muscular  fibres.  In  disease  of  the  efferent 
fibres,  or  of  their  central  or  peripheral  terminations,  the 
reflex  symptoms  are  usually  accompanied  by  voluntary  motor 
disorders. 

(3)  The  grey  substance  of  the  reflex  mechanism  {Fig.  13,  P,  A). 

(4)  The  conducting  path — the  pyramidal  tract — which  con- 
nects the  spinal  centres  with  the  higher  cerebral  centres  {Fig. 
18,  p  t). 

(5)  The  muscular  fibres  themselves. 

Varieties  of  Reflex  Actions. — Reflex  actions  have  been  divided 
into  two  varieties — the  suijerficial,  and  the  deep,  and  although 
it  will  subsequently  appear  that  the  latter  reactions  are  not  true 
reflexes  it  will  be  convenient  to  retain  this  classification  in  the 
meantime. 

§  76.  The  Superficial  Reflexes  are  excited  by  stimulation  of 
the  skin  and  accessible  mucous  membranes. 

The  tests  employed  for  estimating  the  various  degrees  of 
these  reflexes  are  tickling,  pricking,  pinching,  or  gently  scratch- 
ing the  surface,  or  the  application  of  the  faradic  current  to  the 
surface  by  means  of  dry  electrodes  or  of  the  faradic  brush. 

A  series  of  reflex  actions  may  be  obtained  from  the  normal 
spinal  cord,  which,  as  Dr.  Gowers^  has  shown,  are  of  the  utmost 
importance  in  the  diagnosis  of  spinal  affections. 

The  following  superficial  reflexes  may  be  distinguished  : — 

1.  The  reflex  of  the  sole  of  the  foot,  which  depends  upon  the  integrity  of 
the  reflex  arc  through  the  lower  end  of  the  cord  (conus  medidlaris). 

2.  The  gluteal  reflex,  consisting  of  contraction  of  the  gluteal  muscles, 
induced  by  stimidating  the  skin  over  the  buttock,  and  depending  upon  the 
integrity  of  the  arc  through  the  fourth  or  fifth  lumbar  nerves. 

3.  The  cremasteric  reflex,  by  which  the  testicle  is  drawn  up  when  the 

'  The  Diaf?nosis  of  Diseases  of  the  Spinal  Cord,  by  Dr.  W.  R.  Gowers.  The 
Medical  Times  and  Gazette,  Vol.  II.,  p.  526. 


INDIVIDUAL  MOTOR  MECHANISMS.  161 

skill  on  the  inner  side  of  tlie  thigh  is  stimulated,  and  demanding  the 
integrity  of  the  first  and  second  pair  of  lumbar  nerves. 

4.  The,  abdominal  reflex;  consisting  of  a  contraction  of  the  abdominal 
muscles,  chiefly  the  rectus,  caused  by  stroking  the  skin  on  the  side  of  the 
abdomen  from  the  edge  of  the  ribs  downwards,  and  requiring  the  integrity 
of  the  arc  through  the  nerves  from  the  eighth  to  the  twelfth  dorsal  nerves. 

5.  The  epigastric  reflex  producing  a  dimpling  of  the  epigastrium  on  the 
side  stimulated.  It  is  induced  by  stimulation  of  the  side  of  the  chest  in 
the  sixth,  fifth,  and  sometimes  fourth  intercostal  spaces.  This  dimpling 
probably  depends  upon  contraction  of  the  highest  fibres  of  the  rectus 
abdominis,  and  its  presence  requires  the  integrity  of  the  cord  from  the 
fourth  to  the  sixth  or  seventh  pairs  of  dorsal  nerves. 

6.  The  erector  spince  reflex,  consisting  of  a  local  contraction  of  these 
muscles,  caused  by  stimulation  of  the  skin  along  their  edge  from  the  angle 
of  the  scapula  to  the  iliac  crest,  and  demanding  the  integrity  of  the  reflex 
arcs  in  the  dorsal  region  of  the  spinal  cord. 

7.  Tlie  scapular  reflex,  consisting  of  a  contraction  of  some,  or  nearly  all, 
of  the  scapular  muscles  according  to  its  degree,  and  demanding  the  in- 
tegrity of  the  cord  at  the  level  of  the  upper  two  or  three  dorsal  and  lower 
two  or  three  cervical  nerves. 

8.  The  palmar  reflex  consists  of  a  contraction  of  the  flexors  of  the 
fingers  induced  by  tickling  the  palna  of  the  hand.  It  requires  the  integrity 
of  the  reflex  arcs  through  the  greater  part  of  the  cervical  enlargement. 
This  reflex  is  not  readily  induced  during  waking  hours  and  consequent 
cerebral  activity,  probably  because  the  hand  is  much  more  under  cerebral 
influence  than  the  foot.  During  sleep,  however,  and  in  young  infants, 
when  the  cerebral  influence  is  suspended,  or  not  yet  fully  established,  this 
reflex  is  as  readily  induced  as  the  reflex  of  the  sole  of  the  foot. 

9.  Cranial  reflexes. — The  chief  reflexes  of  the  cranial  nerves  are  the 
contraction  of  the  palatal  muscles  caused  by  irritation  of  the  fauces  ; 
the  sneezing  caused  by  irritation  of  the  mucous  membrane  of  the  nose ; 
the  cough  caused  by  irritation  of  the  mucous  membrane  of  the  larynx ;  the 
closure  of  the  eyehds  caused  by  irritation  of  the  conjunctiva;  and  the 
reflex  contraction  of  the  iris  caused  by  Light. 

Some  of  these  reflexes  are  absent  in  healthy  individuals,  more  especially 
the  reflexes  of  the  back  and  abdomen,  so  that  the  diminution  or  absence  of 
these  must  not  be  taken  as  a  sure  sign  of  disease.  Their  presence,  however, 
is  a  proof  that  the  respective  paths  through  the  cord  are  not  seriously 
interrupted. 

Increase  of  these  reflex  reactions  indicates  that  the  irritability  of  the 
respective  arcs  is  increased  in  some  portion  of  their  course,  or  that  the 
inhibitory  influence  of  the  cerebrum  is  withdrawn.  When  a  frog  is  poisoned 
with  strychnia,  a  slight  touch  on  any  part  of  the  skin  may  cause  convul- 
sions of  the  whole  body,  due,  as  Dr.  Ringer  has  shown,  to  diminution  of 
the  specific  resistance  of  the  grey  substance.  A  similar  increase  of  the 
reactions  obtained  by  cutaneous  stimulation  occurs  in  strychnia  poisoning 

VOL.  I.  L 


162  ELEMENTARY  AFFECTIONS  OF 

in  man.  When  the  brain  of  the  frog  is  removed  reflex  actions  are  developed 
to  a  much  gi-eater  degree  than  in  the  entire  animal ;  but  if  the  optic  lobes 
be  stimulated  by  putting  a  crystal  of  sodium  chloride  upon  them  the 
activity  of  the  reflex  actions  becomes  again  diminished.  That  withdrawal 
of  cerebral  influence  increases  the  reflex  activity  of  the  spinal  cord  in  man 
is  shown  by  the  facts  that  the  reflexes  are  very  active  during  sleep  and  in 
childhood. 

The  condition  of  the  cutaneous  reflexes  in  cerebral  paralysis,  however, 
appears  to  be  an  exception  to  this  rule,  inasmuch  as  they  become  greatly 
diminished  or  abolished  on  the  paralysed  side.  It  has  been  shown  by 
Rosenbach  that  the  abdominal  reflexes,  and  by  Jastrowitz  that  the 
cremasteric  reflexes,  are  abohshed  or  diminished  on  the  paralysed  side 
in  cases  of  disease  of  one  cerebral  hemisphere.  These  curious  facts  may 
probably  be  due  to  paralysis,  or  loss  of  tone  of  the  muscular  fibres  dis- 
tributed to  the  skin,  which  may  be  followed  by  so  much  cutaneous 
flaccidity  as  to  prevent  the  peripheral  termination  of  the  afferent  fibres  of 
the  reflex  arcs  from  being  duly  exposed  to  the  irritation  of  tickling  and 
other  cutaneous  stimulants.  But,  whatever  may  be  the  explanation,  there 
can  be  no  doubt  that  these  phenomena  are  only  apparent  and  not  real 
exceptions  to  the  general  law,  that  diminution  of  cerebral  influence 
increases  the  reflex  activity  of  the  cord,  the  other  conditions  of  reflex 
action  being  normal. 

§  77.  The  Deep  Reflexes. 

The  phenomena  which  have  been  grouped  under  the  name  of 
deep  reflexes  consist  of  muscular  contractions,  evoked  by  striking 
the  muscles  themselves,  or  stretching  their  tendons,  or  even,  under 
certain  circumstances,  by  tapping  certain  parts  of  the  periosteum, 
and  probably  some  of  the  fascise.  As  the  mechanical  reflex 
contractility  of  the  muscle  is  subject  to  the  same  laws  as  the 
tendinous  reactions,  the  former  does  not  demand  a  separate 
examination. 

§  78.  Tendon-'pevcvbssion  Contractions. — Of  the  tendon  re- 
action's, by  far  the  best  known  are  those  which  have  been  called 
respectively  patellar-tendon  and  Achilles-tendon  reflex,  by  Erb,^ 
and  "knee-phenomenon"  and  "foot-phenomenon"  by  Westphal.^ 
The  former  has  also  been  called  knee-jerk  and  the  latter  ankle 

^  Erb  (Prof.  W.).  "  Sehnenreflexe  bei  Gesiinden  und  bei  "RuckenmarkskrankaTi." 
Archiv.  f.  Psychiat.  Berl.  Band  IV.,  1875,  p.  792. — '"  Ueber  einen  wenigbekannten 
Spinalen  Syraptomencomplex."    BerL  Klin.  Wocbenschrift,  1875,  No.  26. 

^  Westphal  (Prof.  C).  "  Ueber  einige  Bewegungs-Erscheinungen  an  gelabmten 
Gliedem."    Arch.  f.  Psychiat.     Bd.  IV.,  1875,  p.  883. 


INDIVIDUAL   MOTOR  MECHANISMS.  163 

clonus,  and  as  these  terms  do  not  involve  any  theory  with  regard 
to  the  production  of  the  phenomena  we  prefer  to  use  them  chiefly. 
Knee-jerk — 'If  a  man  in  health  sits  with  one  leg  crossed  upon 
the  other,  and  the  ligamentum  patellae  be  then  smartly  struck 
immediately  below  the  knee-cap,  the  extensor  muscles  in  front 
of  the  thigh  become  suddenly  contracted  causing  the  foot  to  be 
jerked  forwards  to  a  variable  extent,  according  to  the  degree  of 
the  contraction. 

The  blow  is  usually  delivered  by  the  inner  edge  of  the  hand  of  the 
operator ;  but  an  ordinary  stethoscope,  held  loosely  by  the  small  end  while 
the  blow  is  struck  with  the  edge  of  the  ear-piece,  is  a  convenient  instrument 
for  the  purpose  ;  while,  in  cases  which  require  great  delicacy  in  the  appli- 
cation of  the  test,  it  is  desirable  to  use  a  Winterich  percussion  hammer  for 
the  purpose.  It  is  also  desirable  to  uncover  the  knee  that  the  blow  may 
be  delivered  on  the  bare  skin. 

The  usual  sitting  posture,  with  the  legs  crossed  so  that  the  back  of  one 
knee-joint  rests  on  the  front  of  the  other,  is  the  position  generally  adopted 
for  applying  the  test ;  but  any  position  will  suffice  which  renders  the 
tendon  tense  and  leaves  the  leg  free  to  move  so  as  to  indicate  the  contraction. 
Sitting  on  an  elevated  seat,  the  legs  hanging  freely,  is  also  a  convenient 
position ;  and  in  stout  people,  who  cannot  readily  cross  one  leg  over  the 
other  in  a  sitting  postm-e,  the  operator  may  pass  his  hand  beneath  the 
patient's  thigh  just  above  the  knee  joint,  and,  grasping  the  opposite  knee, 
support  the  extremity  to  be  examined  by  his  forearm  (Gowers). 

The  reaction  is  most  energetic  when  the  blow  is  struck  a  little  below 
but  very  near  to  the  patella ;  and  it  may  be  necessary  to  make  repeated 
trials  before  the  most  sensitive  spot  is  discovered.  Although  the  most 
sensitive  spot  is  over  the  tendon  immediately  below  the  patella,  the  con- 
traction may  also  be  excited,  more  especially  when  the  reaction  is  lively,  by 
a  blow  on  the  tendon  above  the  patella,  or  even  by  a  blow  on  the  muscle. 

The  strength  of  the  contraction  varies  greatly  vsdthin  the  limits  of 
health  in  different  individuals,  and  even  in  the  same  individual  at  different 
times.  With  myself  this  reflex  is  at  times  very  lively;  while  at  other 
times  it  is  not  readily  elicited,  although  the  phenomenon  is  always  present 
to  some  extent.  The  conditions  which  determine  these  variations  are  not 
clearly  traceable,  but  it  is  probable  that  the  reaction  may  be  absent  in 
healthy  persons.  Out  of  1,409  healthy  individuals  examined  by  Berger  the 
patellar  reflex  was  absent  in  22,  or  1'56  per  cent.^ 

The  mechanism  by  which  this  reaction  is  produced  has  been  much 
discussed  of  late.  It  is  conceivable  that  the  contraction  of  the  quadriceps 
is  produced  by  the  direct  irritation  of  the  muscular  fibres  which  their 
sudden  stretching  causes  ;  or  that  it  is  of  the  nature  of  a  true  spinal  reflex. 

'  Centralbl.  fiir  Nervenheilkunde,  No.  4.    1879. 


164  ELEMENTARY  AFFECTIONS   OF 

If  the  reaction  be  a  true  spinal  reflex,  it  must  conform  to  tlie  laws 
wMcli  regulate  tlie  genesis  and  transmission  of  other  reflex  acts,  and  must 
consequently  possess  the  following  characteristics : — 

1.  It  must  take  its  origin  from  stimulation  of  afferent  fibres. 

2.  It  ought  to  be  diminished  or  abohshed  by  all  injuries  and  diseases 
which  diminish  or  abohsh  the  irritabihty  of  any  portion  of  the  reflex  arc 
concerned  in  its  production  ;  and  conversely  it  ought  to  be  augmented  by 
those  lesions  which  increase  the  irritability  of  any  portion  of  that  arc. 

3.  An  interval  must  intervene  between  the  instant  at  which  the  blow 
is  delivered  on  the  tendon  and  the  commencement  of  the  contraction  of 
the  quadriceps,  corresponding  to  the  time  occupied  in  the  transmission  of 
other  reflex  impulses. 

1.  The  first  requirement  laid  down  is  that  the  reflex  act  must  take  its 
origin  from  stimulation  of  afferent  fibres.  Now  if  the  knee-phenomenon 
be  a  true  reflex  it  must  conform  to  this  requirement,  and  the  origin  of  the 
afferent  fibres  concerned  must,  if  possible,  be  determined.  The  afferent 
fibres  of  the  knee-phenomenon  might  spring  from  the  skin  over  the  tendon, 
from  the  tendon  itself,  or  from  the  muscles.  That  the  cutaneous  nerves 
are  not  concerned  in  the  reaction  has  been  amply  proved  by  Westphal  and 
others.  Westphal  could  not  induce  any  contraction  in  the  muscle  by 
pinching  the  skin  over  the  tendon,  or  by  striking  it  with  a  percussion 
hammer  after  being  raised  up  in  a  fold  so  that  it  could  be  struck  without 
acting  on  the  underlying  tendon  ;  and  the  reaction  is  readily  obtained  in 
animals  by  striking  the  bare  tendon  after  the  skin  has  been  cut. 

It  is  not  so  easy  to  determine  whether  the  afferent  fibres  start  from  the 
tendon  or  from  the  muscle,  but  it  may  be  stated  in  favour  of  the  former  of 
the  two  suppositions  that  Sachs  has  demonstrated  the  existence  of  nerve 
fibres  in  the  tendon  of  the  quadriceps,  these  being  especially  abundant  at 
the  point  of  junction  of  the  tendon  with  the  muscles. 

2.  The  second  condition  of  a  reflex  action  is  that  increase,  diminution,  or 
abohtion  of  the  irritability  of  the  reflex  arc  should  give  rise  to  corresponding 
variations  in  the  activity  of  the  tendon-jerk. 

Schultze  and  Fiirbinger^  found  that  the  knee-jerk  exists  in  animals, 
and  that  it  is  abolished  on  the  destruction  of  the  spinal  cord.  Tschirjew 
a,lso  found  that  destruction  of  the  portion  of  the  spinal  cord  of  the  hare, 
opposite  the  fifth  and  sixth  lumbar  vertebrae,  and  from  which  the  greater 
portion  of  the  anterior  crural  nerve  springs,  as  well  as  section  of  the  pos- 
terior roots  of  the  sixth  lumbar  pair  of  nerves,  immediately  arrested  the 
knee-reflex,  while  section  of  the  cord  above  and  below  this  point  did  not 
exert  any  manifest  influence  on  its  production.  These  observations  have 
since  been  confirmed  by  Senator,'^  who  also  found  that  unilateral  section 
of  the  cord  between  the  fifth  and  sixth' lumbar  nerves  arrested  the  tendon- 

'  Schultze  and  Fiirbinger.     Centralbl.  f.  d.  med.  Wissensch.     1875,  p.  929. 

"  Senator  (H.).  "  Ueber  Sehnenreflexe  und  ihre  Beziehung  zum  Muskeltonus." 
Arch.  f.  Anat.  und  Physiol.     Leipzig,  1880.    p.  197. 


INDIVIDUAL  MOTOK  MECHANISMS.  165 

reaction  on  tlie  side  of  the  lesion.  It  ought  to  be  mentioned  that  Burck- 
hardt  states  that,  although  section  of  the  anterior  crural  nerve  in  animals 
arrests  the  knee-reflex,  yet  it  is  not  arrested  by  section  of  the  spinal  roots, 
and  hence  he  concludes  that  the  phenomenon  is  a  reflex  from  the  ganglia 
of  the  posterior  roots.  This  conclusion  is,  however,  contrary  to  well  ascer- 
tained pathological  facts,  and  the  experiment  upon  which  it  is  founded  is, 
moreover,  contradicted  by  the  positive  results  obtained  by  Tschirjew. 
Prevost  observed  that  tapping  of  the  patellar  tendon  of  one  leg  gave  rise 
to  a  contraction  of  the  quadriceps  femoris  of  the  opposite  leg,  as  well  as  to 
that  of  the  same  side ;  and  he  naturally  adduced  this  fact  as  a  proof  of  the 
reflex  nature  of  the  phenomenon.  In  association  with  Waller'^  he  has  since 
foimd  that  section  of  all  the  nerves  and  posterior  nerve  roots  of  one  limb 
does  not  abolish  this  crossed  contraction,  and  consequently  the  latter  must 
be  regarded  as  "  due  to  the  physical  diflFusion  of  vibration."  This  opinion 
is  confirmed  by  de  Watteville,  who  showed  that  the  latency  of  contraction 
in  the  opposite  leg  is  identical  with  that  in  the  leg  percussed,  and  this 
latent  period,  as  will  be  immediately  shown,  is  much  too  short  for  a  reflex 
contraction  to  take  j)lace.  It  occurred  to  Westphal,^  that  the  muscular 
tonus  of  the  quadriceps  femoris  upon  which  he  beUeves  the  knee-jerk 
to  depend  might  be  restored  in  animals  by  the  administration  of 
strychnine  after  it  had  been  previously  abolished  by  sections  of  the 
posterior  roots  in  the  lumbar  region.  The  necessary  experiments  to 
test  this  question  were  performed  by  Munk,  but  the  results  were 
negative.  In  one  experiment,  indeed,  the  administration  of  strychnine 
restored  the  knee-jerk  after  it  had  been  previously  abolished  by  section  of 
some  of  the  posterior  roots,  but  a  post-mortem  examination  revealed  the 
fact  that  it  was  the  fourth  and  fifth  posterior  lumbar  roots  which  were  cut 
instead  of  the  fifth  and  sixth  roots  as  was  supposed  during  life.  This 
experiment  shows  that  division  of  a  few  of  the  afferent  fibres  of  the  crural 
nerve  suffices  to  arrest  the  reaction,  and  that  the  mechanism  which 
regulates  it  must  be  an  exceedingly  delicate  one.  These  experiments  taken 
as  a  whole  prove  that  the  integrity  of  the  reflex  arc  is  necessary  to  the  pro- 
duction of  the  knee-jerk,  and  in  order  to  see  whether  or  not  the  phenomenon 
itself  is  of  the  nature  of  a  true  reflex  we  must  turn  to  the  third  characteristic 
of  a  reflex  action. 

3.  Let  us  now  see  if  the  patellar-tendon  reflex  conforms  to  the  third  and 
last  requirement  of  a  reflex  act.  We  have  already  found  that  if  x  is  equal  to 
the  combined  lengths  of  the  afferent  and  efferent  fibres  of  a  reflex  arc,  the 
time  which  intervenes  between  an  impression  and  the  resulting  contraction 
is  equal  to  "03  x  +  "055  -f-  "01  of  a  second.  Now,  suppose  that,  with  Dr. 
Gowers,  we  assume  that  the  length  of  the  afferent  and  efferent  fibres  of  the 
knee  reflex  arc — that  is,  the  length  from  the  tendon  to  the  spinal  cord  at 
the  level  of  the  origin  of  the  sixth  lumbar  nerve  and  back  again  to  the 

1  Waller  (Augustus).     "  On  Tenrlon-Reflex."    The  Lancet,  Vol.  II.,  1881,  p.  83. 
*  Westphal  (C).     "  Ueber  eine  Fehlerquelle  bei  Untersuchung  des  Kniephii- 
Domen's  unci  iiber  dieses  selbst."    Arch.  f.  Psychiat.     Bd.  XII.,  1882,  p.  803. 


16G  ELEMENTARY  AFFECTIONS   OF 

middle  of  the  quadriceps  muscle — is  equal  to  a  metre  and  a  half  (which  is 
rather  too  much),  then  our  formula  is  •03Xl'54-'055+'01  =  *ll,  or  about  -} 
of  a  second. 

The  graphic  method  has  been  employed  by  several  observers  in  order 
to  determine  whether  the  interval  between  the  blow  on  the  tendon  and  the 
contraction  of  the  quadriceps  corresponds  to  the  conclusion  derived  from 
the  reflex  formula.  There  is  now  a  pretty  general  agreement  amongst 
experimenters  that  the  interval  of  time  between  the  blow  and  the  con- 
traction is  not  sufficiently  long  for  a  reflex  act  to  take  place.  Burckhardt,^ 
who  was  the  first  to  apply  the  graphic  method,  fomid  the  length  of  the 
interval  between  the  blow  and  the  contraction  to  be  '039  of  a  second  ; 
Tscliirjew,^  'OSB  seconds;  and  Waller,^  -04;  while  Brissaud  and  Frangois- 
Franck,  who  conducted  observations  on  this  point  under  the  direction  of 
Charcot,*  found  the  length  of  the  interval  to  be  '04  sec.  in  health,  and  -036 
in  lateral  sclerosis,  in  which  the  reaction  is  exaggerated.  Eulenburg^  has 
found  from  a  large  number  of  experiments  that  the  duration  of  the  latency 
rarely  exceeds  '032  sec,  and  it  is  not  unfrequent  to  meet  vdth  it  as  short  as 
•016  sec.  in  healthy  individuals.  In  pathological  conditions,  such  as  lateral 
sclerosis,  in  which  the  knee-jerk  is  exaggerated,  the  length  of  the  latent 
period  is  diminished  to  "016  of  a  second ;  it  is  notably  shortened  by  injections 
of  strychnia,  and  considerably  lengthened  by  some  anaesthetics  and  narcotics, 
as  chloroform,  bichloride  of  methylene,  and  bromides.^  Through  the  kindness 
of  Dr.  de  Watteville  I  have  had  an  opportunity  of  witnessing  the  measure- 
ment of  the  latent  period  of  the  knee-jerk  by  the  ingenious  apparatus 
devised  by  Dr.  Waller,  and  nothing  could  be  more  simple  yet  more  adequate 
for  the  purpose.  By  means  of  this  apparatus  Dr.  de  Watteville'^  has  found 
that  the  interval  between  an  impression  made  on  the  skin  of  the  sole  of  the 
foot  and  the  resulting  contraction  of  the  quadriceps  femoris  corresponds 
pretty  accurately  with  that  of  a  true  reflex  (Fig.  12,  3),  as  calculated  from 
experiments  on  animals  ("1  sec),  and  that  it  is  three  times  as  long  as  the 
latent  period  of  the  knee-jerk  (Fig.  12,  2).  A  direct  comparison  of  the 
latent  period  of  the  knee-jerk  and  the  plantar  reflex  in  the  same  individual 
is  manifestly  of  great  value,  inasmuch  as  calculations  based  upon 
experiments  on  animals  are  liable  to  many  sources  of  error.  Dr.  de 
Watteville  also  discovered  by  myographic  tracings  that  there  is  a  double 

>  Burckhardfc  (G.).  "  Ueber  Sehnenreflexe."  Abst.  Canstatt's  Jahrb.,  1879. 
I.,  183. 

^  Tschirjew.  "  Ursprung  und  Bedeutung  des  Kinephanomens  und  verwandter 
Erscheinungen."    Arch,  fiir  Psychiat.     Berlin,  1877.     Bd.  VIIL,  s.  689. 

^Waller  (Augustus).  "On  Muscular  Spasms  known  as  'Tendon-Reflex.'" 
Brain.     Vol.  III.    Lond.,  1880-1.     p.  179. 

*  Le  Progres  Medical,  13  Mars,  1880,  p.  204. 

*  Eulenburg.  "  Ueber  die  Latenzdauer  der  SebnenphEinomene."  Neurologische 
Centralblatt.     Leipzig,  1882.     No.  L,  p.  3. 

"Eulenburg.  "  On  Graphic  Tracings  of  Tendon-reflexes."  Transactions  of  the 
International  Medical  Congress,  London,  Vol.  II.,  1881,  p.  42. 

'  De  Watteville.  '"  On  Reflexes  and  Pseudo-reflexes."  British  Medical  Journal, 
London,  1882,  Vol.  I.,  p.  736. 


INDIVIDUAL  MOTOR  MECHANISMS. 


167 


contraction  of  the  quadriceps  when  the  patellar  tendon  is  struck  through 
the  skin  {Fig.  12,  1) ;  the  latent  period  of  the  first  is  from  -02  to  -03  of  a 
second,  or  the  usual  knee-jerk  latency,  and  that  of  the  second  from  "08  to 
•1  of  a  second,  or  the  latency  of  a  true  reflex.  The  second  contraction  he 
believes  to  be  caused  by  the  cutaneous  impression.  This  fact  is  of  great 
clinical  importance,  and  WestphaP  has  shown  that  the  knee-jerk  may  be 
produced  in  different  diseases  by  excitation  of  the  skin  over  the  patellar 
tendon.  The  possibihty  of  mistaking  a  skin-reflex  for  the  tendon-reaction 
should  be  constantly  kept  in  view  in  the  clinical  examination  of  the 
knee-jerk.  From  these  experiments  it  would  appear  certain  that  the  knee- 
jerk  is  not  caused  by  reflex,  but  by  direct  action,  and  that  it  is  due,  as 
was  at  first  supposed  by  Westphal,  to  the  sudden  stretching  of  the  muscular 
substance  itself.  It  is  at  the  same  time  of  great  importance  to  notice  that 
the  integrity  of  the  reflex  loop  is  necessary  to  its  production,  and  that  the 
reaction  is  readily  abohshed  by  disease  of  the  spinal  centres,  or  of  the 
afferent  or  efferent  nerve  paths.  It  would  seem  that  the  reaction  does  not 
take  place  unless  a  certain  degree  of  tonus  is  maintained  in  the  muscle,  and 
that  the  reflex  influence  is  necessary  for  the  maintenance  of  this  condition. 
The  great  practical  consideration  for  the  physician  is  that  this  reaction, 
although  not  a  true  reflex,  may  be  unhesitatingly  accepted  as  a  valuable 
clinical  test  in  spinal  diseases,  and  in  lesions  of  peripheral  nerves  and 
nerve  roots. 

Fig.  12. 


Fig.  12  (after  De  Watteville). — Line  4,  time-tracing,  fifty  vibrations  a  second. 
Line  3,  plantar-reflex;  at  (a)  stimulation  of  skin,  at  (c)  contraction  of  the  ex- 
tensor femoris.  Line  2,  knee-jerk  of  same  subject;  at  (a)  percussion  wave 
caused  by  impact  of  blow,  (6)  contraction  of  the  extensor  femoris.  Line  1, 
tracing  obtained  from  patient  with  marked  knee-jerk  and  exaggerated  cutaneous 
rrflexes ;  {a)  percussion  wave,  {h)  usual  knee-jerk,  (c)  further  contraction  re- 
garded as  a  true  reflex. 

'  Arch.  f.  Psychiatrie.     Bd.  XII.,  1882,  p.  798. 


168  ELEMENTARY  AFFECTIONS   OF 

,  §  79.  Diseased  Conditions  under  which  the  Knee-jerk  is 
diminished  or  abolished. — (1)  The  knee-jerk  is  absent  in 
most  cases  of  locomotor  ataxy,  and  the  diagnostic  value  of  this 
symptom  is  greatly  enhanced  by  the  fact  that  the  pheno- 
menon usually  disappears  at  a  very  early  period  of  the  affection. 
It  is  now  well  known  that  the  morbid  lesion  in  locomotor 
ataxy  is  situated  in  the  posterior  root -zones  {Fig.  13,  pr) 
and  posterior  roots,  and  consequently  the  absence  of  the  knee- 
jerk  is  usually  associated  with  lightning  pains  and  various 
other  sensory  disturbances.  It  is  probable,  therefore,  that 
conduction  through  the  patellar-tendon  reflex  arc  is  arrested 
in  this  affection  in  the  afferent  fibres  towards  their  insertion 
into  the  posterior  grey  horns  of  the  cord,  the  exact  locality 
being  the  internal  bundle  of  the  posterior  root,  or  what  Charcot 
calls  the  inner  radicular  fasciculus  {Fig.  13,  p'r).  Senator,^ 
however,  found  that  in  the  hare,  although  section  of  the  cord 
opposite  the  fifth  and  sixth  lumbar  vertebrae  arrested  the  reaction, 
yet  neither  section  of  the  posterior  columns,  posterior  horns,  nor 
anterior  horns  in  this  locality  had  any  influence  upon  it.  On  the 
other  hand,  it  was  arrested  by  section  of  the  lateral  columns  and 
the  adjoining  grey  substance.  It  is  therefore  probable  that  the 
afferent  fibres  of  this  reflex  arc  pass  into  the  posterior  grey  horn 
in  the  hare  in  the  external,  instead  of  the  internal  bundle  of  the 
posterior  roots  as  in  man,  Erb  has  shown  that  in  those  cases  in 
which  the  knee-jerk  is  completely  abolished  a  slight  contraction 
of  the  quadriceps  femoris  may  still  be  obtained  by  dealing  a 
smart  blow  across  the  middle  of  the  muscle  with  the  edge  of  the 
extended  hand,  showing  that  the  mechanical  contractility  of  the 
muscle  is  retained,  although  the  tendon-jerk  is  abolished. 

The  posterior  roots  of  the  nerves  are  also  not  unfrequently 
implicated  in  cases  of  spinal  meningitis,  and  in  a  case  of  the 
kind  under  my  care,  attended  by  shooting  pains  but  without 
distinct  diminution  of  any  form  of  sensibility,  both  the  cutaneous 
reflexes  and  the  tendon-reactions  were  absent  in  the  lower  ex- 
tremities ;  while  the  absence  of  muscular  atrophy,  of  any  decided 
loss  of  faradic  and  galvanic  contractility,  and  of  the  reaction  of 
degeneration,  showed  that  neither  the  anterior  roots  nor  the 
anterior  grey  horns  were  decidedly  implicated  in  the  disease. 

'  Senator  (H.).     Arch.  f.  Anat.  und  Physiol.    Leipzig,  1880.    p.  200. 


INDIVIDUAL  MOTOE  MECHANISMS. 


169 


(2)  The  knee-jerk  is  also  abolished  in  diseases  of  the  anterior 
grey  horns  {Fig.  13,  A),  attended  with  muscular  atrophy,  and 
doubtless  also  in  disease  of  the  efferent  fibres  of  the  anterior 
roots  (Fig.  13,  a,  a,  a)  and  of  the  crural  nerve.  The  knee-jerk 
is  absent,  for  instance,  in  infantile  paralysis,  implicating  the 

Fig.  13. 


Fig.  13.  Section  of  Spinal  Cord  from  the  Middle  of  the  Lumbar  Enlargement. — 
A  and  P,  Anterior  and  Posterior  Grey  Cornua  respectively ;  sg.  Substantia 
Gelatinosa  ;  cc.  Central  Canal ;  ae,  pc,  Anterior  and  Posterior  Commissures 
respectively  ;  G,  Column  of  GoU  ;  pr,  Posterior  Root  Zone  ;  p,  Posterior  Root ; 
p'r,  Internal  Radicular  Fasciculus;  a,  a,  a,  Anterior  Roots;  ar,  ar',  Anterior 
Root  Zone ;  fr,  Formatio  Reticularis ;  pt,  Pyramidal  Tract. 


170  ELEMENTARY  AFFECTIOYS   OF 

quadriceps  muscle,  and  in  the  more  or  less  advanced  stages  is. 
pseudo-hyper  trophic  paralysis. 

(3)  It  is  not  necessary  that  disease  of  the  grey  substance 
should  be  a  permanent  one  in  order  to  diminish  the  activity  of 
the  knee-jerk.  Large  doses  of  bromide  of  potassium  lower  the 
irritability  of  the  grey  substance  of  the  cord,  and  so,  according 
to  Berger,  do  large  doses  of  opium,  and  free  administration  of 
these  agents  diminishes  the  activity  of  the  tendon-reaction. 

(4)  Increase  of  cerebral  influence  on  the  grey  substance  of  the 
spinal  cord  diminishes  the  activity  of  the  tendon-contractions  as 
it  does  true  reflex  actions.  The  knee-jerk  can  undoubtedly  be 
arrested  by  a  voluntary  effort ;  and  during  the  convulsive  stage 
of  an  epileptic  attack,  which  is  caused  by  an  excessive  cortical 
discharge,  I  have  found  that  not  the  slightest  effect  could  be 
produced  on  the  contractions  of  the  quadriceps  by  striking  its 
tendon.  This  observation  is  of  course  of  very  little  consequence, 
but  it  is  mentioned  because  the  converse  statement  that  the 
knee-jerk  is  increased  by  diminution  of  cerebral  influence  on 
the  cord  is  of  such  very  great  importance. 

§  80.  Diseased  Conditions  in  which  the  Knee-jerk  is  exag- 
gerated.—  (1)  As  already  remarked,  whatever  increase?  the 
irritability  of  the  reflex  loop  concerned  in  the  reactioL,  or 
diminishes  the  cerebral  influence  on  the  spinal  cord,  increases 
the  activity  of  the  tendinous  contractions.  It  is  probable  that 
irritation  of  the  peripheral  terminations  of  both  the  afferent  and 
efferent  nerve  fibres  will  increase  the  activity  of  the  reaction, 
although  no  crucial  examples  of  the  kind  have  as  yet  been 
described.  When,  however,  the  irritability  of  the  muscular 
fibres  themselves  is  increased,  as  in  phthisis  and  other  ex- 
hausting diseases,  the  tendinous  contractions  are  much  more 
readily  induced  than  in  health. 

(2)  Irritation  of  the  posterior  roots  of  the  nerves  probably 
also  increases  the  tendinous  contractions ;  but  direct  evidence 
upon  this  point  is  wanting  as  yet.  We  have  seen  that  the 
knee-jerk  is  usually  absent  in  an  early  stage  of  locomotor  ataxy ; 
but  it  is  worth  while  to  observe  closely  whether  its  abolition 
may  not  be  preceded  by  a  transitory  period  of  exaggerated 
reaction,  just  as  ansesthesia  is  often  preceded  by  hyperaesthesia. 


INDIVirjCJAL   MOTOR   MECHANISMS.  171 

.  J  a,  case  under  my  care  there  were  for  some  time  distinct 
ataxic  symptoms  along  with  excess  of  the  patellar-tendon 
reaction  ;  but  as  I  have  now  lost  sight  of  the  case  it  would  be 
hazardous  to  declare  that  it  was  one  of  true  locomotor  ataxy. 
The  reaction  probably  does  occasionally  persist  in  genuine  cases 
of  locomotor  ataxy,  although  I  am  not  aware  that  it  has  ever 
been  described  as  exaggerated. 

(3)  Increased  irritability  of  the  grey  substance  of  the  spinal 
cord  is  attended  with  increase  of  the  patellar-tendon  reaction  ; 
hence  activity  of  the  phenomenon  is  increased  by  the  administra- 
tion of  strychnia.  It  is  also  very  probable  that  it  may  be  found 
increased  in  the  early  stages  of  acute  diseases  affecting  the  grey 
substance  of  the  cord,  such  as  tetanus,  hydrophobia,  and  acute 
central  myelitis. 

(4)  By  far  the  most  important  condition,  under  which  excess 
of  patellar-tendon  reaction  occurs,  is  that  in  which  the  cerebral 
influence  is  withdrawn  from  the  spinal  cord  by  disease  of  some 
portion  of  the  pyramidal  tract.  The  effect  on  this  reaction  is  the 
same,  no  matter  at  what  level  the  disease  of  the  pyramidal  tract 
is  situated,  whether  at  the  origin  of  these  fibres  in  the  cortex  of 
the  brain,  in  their  passage  through  the  corona  radiata,  internal 
capsule,  pons,  medulla  oblongata,  or  in  the  spinal  cord  itself 
{Fig.  13,  jpt).  The  only  condition  necessary  for  the  subsequent 
development  of  the  exaggerated  reaction  is,  that  conduction 
through  the  fibres  of  the  tract  be  interrupted  in  any  part  of 
their  course.  But,  although  withdrawal  of  the  cerebral  influence 
from  the  lumbar  portion  of  the  cord  is  the  necessary  antecedent 
of  the  exaggerated  reaction  of  the  patellar-tendon,  it  would 
appear  that  some  other  changes  must  take  place  before  its 
activity  is  fully  developed.  When  the  fibres  of  the  pyramidal 
tract  are  ruptured  in  the  internal  capsule  by  a  sudden  effusion 
of  blood  into  the  lenticular  nucleus,  hemiplegia  of  the  opposite 
side  results ;  yet  the  exaggeration  of  the  knee-jerk  does  not 
become  manifest  until  from  eight  to  fourteen  days  after  the 
attack.  It  is  now  well  known  that  the  fibres  of  the  pyra- 
midal tract  below  the  point  of  rupture  undergo  a  descending 
degeneration,  a  process  which  occupies  a  period  of  from  one  to 
two  months.  Closely  associated  with  the  completion  of  this  pro- 
cess, at  least  with  respect  to  time,  is  the  occurrence  of  increased 


172  ELEMENTARY  AFFECTIONS   OF 

tension  in  the  paralysed  muscles,  giving  rise  to  the  contrctcture 
already  described,  and  constituting  what  has  been  described  as 
the  late  rigidity  of  hemiplegic  limbs.  Without  waiting  to 
enquire  into  the  cause  of  late  rigidity  it  is  probable  that  when 
it  is  once  established  the  peripheral  terminations  of  both  the 
afferent  and  efferent  fibres  are  maintained  in  a  constant  state  of 
irritation  by  the  continuous  muscular  tension,  and  that  this  con- 
dition adds  to  the  irritability  of  the  reflex  arc  already  in  excess 
from  arrest  of  the  inhibitory  action  of  the  brain  on  the  cord. 
One  forcible  objection  may  be  urged  against  this  view.  Although 
exaggeration  of  the  patellar-tendon  reaction  and  increased  mus- 
cular tension  are  undoubtedly  closely  associated,  yet  the  former 
manifests  itself  unmistakably  in  hemiplegic  limbs  in  from  eight 
to  fourteen  days,  while  the  latter  is  not  established  in  less  than 
from  one  to  two  months  from  the  date  of  the  apoplectic  attack. 
Therefore  neither  the  arrest  of  cerebral  influence,  nor  the  occur- 
rence of  muscular  tension,  nor  both  combined,  will  fully  account 
for  the  presence  of  exaggerated  patellar-tendon  reaction  in  disease 
of  the  pjrramidal  tract;  and  consequently  some  factor  in  its  pro- 
duction must  for  the  present  remain  undetermined.  It  is  right, 
however,  to  add  that  the  knee-jerk  has  been  found  exaggerated 
immediately  after  an  attack  of  unilateral  convulsions,^  which  are 
always  followed  by  temporary  paralysis  of  the  limbs  implicated 
in  the  spasm,  and  even  after  seizures  of  idiopathic  epilepsy.^ 
These  facts  seem  to  indicate  that  diminution  of  the  cerebral 
influence  alone  suffices  to  increase  the  tendon-reactions,  in  the 
absence  of  any  other  co-operating  factor.  The  knee-jerk  is 
sometimes  greatly  exaggerated  in  hysteria,  but  it  is  difficult  to 
know  whether  the  increase  depends  in  such  cases  upon  diminu- 
tion of  cerebral  influence  or  excess  of  the  irritability  of  the 
reflex  arc. 

The  great  fact  which  concerns  us  at  present  is  the  invariable 
presence  of  exaggerated  patellar-tendon  reaction  in  diseases 
of  the  pyramidal  tract,  provided  that  the  spinal  centre  of 
the  anterior  crural  nerve  be  severed  from  the  cortex,  and  the 
occurrence  of  the  phenomenon  be  not  prevented  by  disease 
of  the  reflex  arc  itself.     When  disease  of  the  pyramidal  tracts 

'  Hughlings  Jackson.     Medical  Times  and  Gazette,  Lond. ,  ISSl,  Feb.  12. 
"  Beevor  (C.  E.).    Brain.     VoL  V.,  1882,  p.  56. 


INDIVIDUAL   MOTOR  MECHANISMS.  17.3 

becomes  associated  with  locomotor  ataxy,  for  instance,  the 
patellar-tendon  reaction  remains  as  a  rule  absent  (Westphal). 
I  have  found  it  also  completely  abolished  in  both  legs  in  a 
case  of  meningo-myelitis  in  which  the  presence  of  paralysis 
and  muscular  tension  showed  that  the  pyramidal  tracts  were 
diseased,  while  the  absence  of  atrophy  and  the  maintenance 
of  the  faradic  and  galvanic  contractility  in  both  muscles  and 
nerves  showed  that  the  grey  matter  was  not  affected. 

When  the  knee-jerk  is  exaggerated  the  slightest  tap  on  the 
tendon  induces  an  energetic  contraction  of  the  quadriceps  muscle, 
and  by  repeating  the  blows  in  quick  succession  the  contractions 
occur  so  close  upon  each  other,  and  the  interval  of  relaxation  is 
so  reduced,  that  the  muscle  is  maiotained  in  a  state  of  almost 
tetanic  contraction.  Dr.  Gowers  has  observed  in  cases  where 
the  reaction  is  much  exaggerated  that  a  single  blow  is  followed  by 
a  succession  of  contractions  and  relaxations  similar  to  the  ankle 
clonus,  to  be  hereafter  described. 

Hitherto  I  have  only  spoken  of  the  patellar-tendon  reaction, 
but  similar  phenomena  may  be  obtained  by  striking  the  stretched 
tendons  of  other  muscles.  But  inasmuch  as  no  other  muscle 
besides  the  quadriceps  femoris,  not  even  the  triceps  in  the  upper 
extremit}',  lends  itself  so  readily  to  the  demonstration  of  this 
reaction  in  health,  so  in  no  other  muscle  does  the  absence  of  the 
reaction  afford  such  a  valuable  diagnostic  sign.  Exaggeration  of 
this  reaction  in  other  muscles  is,  however,  as  significant  of  disease 
as  when  it  occurs  in  the  quadriceps.  In  disease  of  the  pyramidal 
tract,  for  instance,  in  which  the  spinal  centres  of  the  upper 
extremity  are  cut  off  from  cerebral  influence,  contractions  may 
be  obtained  from  the  triceps  by  striking  its  tendon  when  the 
forearm  is  flexed  at  right  angles  to  the  arm,  and  from  the 
muscles  which  move  the  fingers,  by  striking  their  tendons  with 
the  edge  of  the  large  end  of  the  stethoscope  as  they  become 
superficial  at  the  wrist  and  back  of  the  hand. 

§  81.  AnJde  Clonus,  or  Achilles-Tendon  Reaction,  consists 
of  a  rhythmical  clonic  spasm,  which  can  be  obtained  under 
certain  circumstances  at  the  ankle-joint.  Unlike  the  patellar- 
tendon  reaction,  ankle  clonus  is  not  a  phenomenon  which  can 
be    readily    induced    in    typically    healthy    individuals.      The 


174  ELEMENTARY   AFFECTIONS   OF 

conditions  necessary  for  the  production  of  this  reaction  can, 
however,  by  a  little  preparation,  be  cultivated  in  most  healthy 
people.  If,  for  instance,  a  healthy  individual  sit  on  the  edge  of 
a  chair,  with  the  leg  forming  an  acute  angle  with  the  thigh,  the 
heel  raised  from  the  ground  and  the  foot  resting  on  the  ball  of 
the  big  toe,  so  that  the  gastrocnemius  is  stretched  ;  and  if  the 
top  of  the  knee  be  now  dealt  a  smart  blow  with  the  palm  of  the 
hand,  the  tension  of  the  gastrocnemius  is  suddenly  increased, 
but  no  perceptible  reaction  ensues  in  healthy  individuals.  But 
if  rhythmic  contractions  of  the  gastrocnemius  be  originated 
voluntarily,  imitating,  for  instance,  the  movements  made  when  an 
infant  is  dandled  on  the  knee,  it  will  soon  be  apparent  that  these 
rhythmic  contractions  are  continued  independently  of  the  will, 
and  require  indeed  a  distinct  effort  of  the  will  to  arrest  them. 

The  neuro-muscular  apparatus  engaged  in  the  production  of 
this  movement  has  now  been  sensitized;  and  a  slight  tap  on  the 
top  of  the  knee  is  immediately  followed,  quite  independently  of 
any  voluntary  effort,  by  clonic  contractions  of  the  gastrocnemius, 
and  consequent  elevations  and  depressions  of  the  heel  and  knee. 
The  occurrence  of  clonic  contractions  of  the  gastrocnemius  in 
this  posture  has  been  observed  by  Dr.  Buzzard  and  Dr.  Gowers, 
and  Waller  has,  by  the  application  of  the  graphic  method, 
proved  that  so  long  as  the  movement  continues,  between  eight 
and  ten  contractions  of  the  gastrocnemius  take  place  in  a  second 
of  time,  each  contraction  being  of  course  followed  by  a  distinct 
relaxation. 

Such,  then,  is  the  ankle  clonus,  as  it  appears  by  cultivation 
in  healthy  subjects ;  but  the  neuro-muscular  mechanism  which 
produces  it  is  sensitized  by  certain  diseases  to  such  an  extent  as 
to  render  any  preliminary  cultivation  unnecessary  to  its  produc- 
tion. The  ankle  clonus  becomes  developed  to  a  high  degree 
under  the  same  circumstances  as  those  in  which  the  patellar- 
tendon  reflex  is  exaggerated ;  the  disease  in  which  it  is  of  the 
greatest  diagnostic  value  being  sclerosis  of  the  pyramidal  tract 
or  lateral  sclerosis.  Under  these  circumstances  the  reaction  can 
be  most  readily  obtained  if  the  operator  will  grasp  the  heel  of 
the  patient  with  his  left  hand,  the  knee-joint  being  nearly  but 
not  quite  extended,  while  with  the  right  hand  he  produces 
dorsal  flexion  of  the  foot  by  pressing  against  the  ball  of  the 


INDIVIDUAL   MOTOR  MECHANISMS.  175 

great  toe,  and  thus  rendering  tense  the  tendo-Achilles.  If  the 
pressure  on  the  latter  be  somewhat  suddenly  made,  the  gastro- 
cnemius almost  immediately  contracts  and  the  toe  is  depressed  ; 
this  is  followed  by  relaxation ;  and  the  pressure  of  the  hand 
being  still  continued  the  toe  is  elevated,  and  a  second  con- 
traction ensues  with  consequent  depression  of  the  toe ;  and  so 
the  contractions  and  relaxations  are  continued  in  rhythmic 
sequence  so  long  as  the  tension  of  the  tendo-Achilles  is  main- 
tained. This  series  of  rhythmic  contractions  constitutes  the 
ankle  clonus.  Two  or  three  weak  contractions  generally  occur 
after  the  pressure  of  the  hand  on  the  ball  of  the  toe  is  with- 
drawn, but  the  contractions  cease  instantly  if  passive  extension 
of  the  foot  is  produced,  so  that  the  Achilles-tendon  is  com- 
pletely relaxed. 

If  the  pressure  on  the  ball  of  the  great  toe  is  very  gradually  and 
steadily  applied,  the  Achilles-tendon  may  be  rendered  tense  without  any 
contraction  being  caused  ;  but,  under  these  circumstances,  a  slight  tap  on 
the  tendon,  or  even  on  the  muscle  itself,  initiates  the  clonus,  which,  being 
once  started,  endures  as  long  as  the  pressure  is  maintained.  Dr.  Gowers 
has  shown  that  a  single  isolated  contraction  of  the  gastrocnemius  may  also 
be  set  up,  the  Achilles-tendon  being  previously  rendered  tense,  by  a  gentle 
tap  over  the  tibiahs  anticus  or  adjacent  muscle;  and  he  proposes  to  call 
this  phenomenon  the  "  front  tap  contraction,"  He  thinks  that  the  con- 
traction is  induced  by  the  vibrations  transmitted  through  the  anterior 
muscles  of  the  leg  and  the  inter-muscular  septum  acting  upon  the  tense 
fibres  of  the  soleus  and  gastrocnemius.  Dr.  Gowers  found  that  the 
interval  between  the  tap  on  the  stretched  Achilles-tendon  and  the  com- 
mencement of  the  resulting  contraction  varied  from  "025  to  "04  of  a  second; 
and  consequently  ankle  clonus  cannot  be  regarded  as  a  true  reflex  any 
more  than  the  knee-jerk. 

There  can  be  no  doubt  that  afferent  fibres  exist  in  the  muscles,  and  just 
as  little  that  passive  extension  of  the  muscle  will  irritate  the  peripheral 
terminations  of  these  fibres.  It  appears  probable  that  muscular  action  is 
governed  by  a  reflex  arc,  the  circuit  of  which  is  closed  by  a  muscular  fibre, 
and  it  is  not  difficult  to  imagine  that,  when  the  muscular  fibres  are  rendered 
tense,  the  afferent  portion  of  the  arc  is  placed  in  a  state  of  irritation ;  and 
that  the  impulses  generated,  on  being  reflected  by  the  cord  through  the 
efferent  portion  to  the  muscular  fibre,  induce  a  condition  of  great  molecular 
instability.  Under  these  circumstances  it  is  probable  that  a  slight  vibra- 
tion passing  through  the  muscular  fibre  would  be  sufficient  to  liberate  its 
energy,  and  to  cause  a  contraction.^    That  the  afferent  fibres  of  the  muscle  are 

1  See  Gowers  (W.  R.\  "A  Study  of  the  so-callerl  Tenflon-Reflex  Phenomena." 
Medico- Chirurg.  Transactions,  Vol.  LXII.,  1879,  p.  269. 


176  ELEMENTARY  AFFECTIONS   OF 

placed  in  a  state  of  irritation  when  tlie  clonus  is  induced  in  the  healthy  is 
shown  by  the  fact  that  a  considerable  amount  of  tenderness  is  developed 
in  the  muscles  of  the  calf,  which  lasts  for  some  time  ;  and  if  passive 
extension  develops  such  a  molecular  sensitiveness  to  liberation  of  energy 
in  the  muscular  fibres  under  the  abnormal  circumstances  we  have  just 
described,  a  similar  relationship  doubtless  exists  between  muscular  tension 
and  the  liberation  of  energy  under  normal  conditions,  which  must  aid  the 
production  of  the  rhythmical  contractions  of  the  muscles,  which  occur  in 
ordinary  locomotion. 

The  practical  point  to  notice  is  that  the  ankle  clonus  is  present  in  a 
marked  degree  in  all  diseases  which  interrupt  the  continuity  of  the  fibres 
of  the  pyramidal  tract,  and  may  even  appear  when  conduction  through 
these  fibres  is  arrested  for  a  prolonged  period,  although  their  continuity 
remain  unimpaired. 

§  82.  Other  Forms  of  Clonus. — Although  the  ankle  clonus 
is  the  best  known  and  most  important  of  the  rhythmical  con- 
tractions obtained  by  suddenly  increasing  the  tension  of  tendons, 
yet  it  is  by  no  means  the  only  instance  of  this  kind  which  may 
be  obtained.  Corresponding  movements  of  the  hand  may  be 
induced  in  cases  of  the  late  rigidity  of  hemiplegia  affecting 
the  upper  extremity,  by  grasping  the  tips  of  the  fingers  and 
pressing  the  hand  backwards  so  as  to  produce  hyperextension 
at  the  wrist. 

A  similar  movement  may  also  be  obtained  in  cases  of  in- 
creased tension  of  the  muscles  of  the  foot  by  producing  sudden 
passive  extension  of  the  first  phalanx  of  the  toe,  the  toe  being 
then  flexed  by  rhythmical  contractions  of  the  abductor  and 
flexor  brevis  pollicis  (Gowers).  Dr.  Gowers  also  describes  a 
lateral  ankle  clonus  caused  by  contraction  of  the  peronei,  and 
induced  by  passive  pressure  of  the  foot  inwards. 

§  83.  Periosteal  and  Fascial  Reactions. — The  best  known  of 
the  muscular  contractions  included  under  this  heading  are  the 
contractions  of  the  quadriceps  femoris  induced  by  gently- 
tapping  the  front  of  the  tibia  near  its  middle.  This  reaction 
can  generally  be  induced  when  the  knee-jerk  is  greatly 
exaggerated.  That  the  quadriceps  contraction  is  not  caused  by 
a  jar  communicated  by  the  patellar-tendon  is  shown  by  the  fact 
that  it  takes  place  when  the  leg  is  extended  and  reposing  its 
whole  length  on  the  bed,  and  consequently  when  the  patellar- 


INDIVIDUAL  MOTOR  MECHANISMS,  177 

tendon  is  thoroughly  relaxed.  The  tibial  tap  is  often  followed 
by  a  contraction  of  the  quadriceps  of  the  opposite  extremity, 
when  the  pyramidal  tracts  of  both  sides  are  diseased.  I  have 
also  observed,  under  these  circumstances,  the  tap  to  be  followed 
by  an  energetic  contraction  of  the  adductors  of  the  opposite  leg. 
When  the  upper  extremity  is  the  subject  of  late  rigidity  a 
slight  tap  with  the  edge  of  the  stethoscope  on  the  lower  end  of 
the  radius  is  followed  by  contraction  of  the  biceps,  and  a  similar 
tap  on  the  lower  end  of  the  ulna  by  contraction  of  the  triceps. 
That  these  contractions  do  not  necessarily  result  from  the 
sudden  flexion  or  extension  of  the  forearm  caused  by  the  blow 
is  evinced  by  the  fact  that  the  reactions  take  place  when  the 
forearm  is  supported,  so  that  both  flexion  and  extension  are 
prevented.  When  the  muscles  of  the  shoulder  and  forearm  are 
implicated  in  the  rigidity,  a  contraction  of  the  pectoralis  major, 
deltoid,  and  biceps  may  be  obtained  by  a  gentle  tap  on  the 
sternal  end  of  the  clavicle ;  and  even  a  crossed  reaction  may 
be  obtained  by  a  tap  on  the  clavicle  of  the  opposite  side. 

A  considerable  number  of  the  muscles  of  the  scapula  and 
shoulder  contract  on  tapping  the  spine  of  the  scapula.  In  a 
case  of  advanced  phthisis  under  my  care  a  slight  tap  over  the 
costal  cartilage  of  the  third  rib  on  the  right  side  is  followed  by 
contractions  of  the  muscles  of  the  left  side  of  the  chest,  and 
extending  not  simply  over  the  pectoral  muscles,  but  as  far  as 
those  of  the  upper  arm  and  the  abdominal  muscles. 

Contractions  of  the  erector  muscles  of  the  spine  may  under 
certain  circumstances  be  induced  by  tapping  the  lumbar  fascia; 
and  in  a  case  of  rigidity  of  the  scapular  muscles  of  one  side 
subsequent  to  hemiplegia  under  my  observation,  the  slightest 
tap  over  the  upper  dorsal  and  lower  cervical  vertebrae,  or  over 
the  muscles  themselves,  was  followed  by  distinct  contraction  of 
the  rhomboid  muscles  on  the  affected  side,  while  no  reaction  of 
this  kind  could  be  obtained  on  the  healthy  side.  These  reactions, 
excepting  the  contraction  of  the  pectoral  muscles  in  the  case  of 
phthisis,  are  obtained  under  analogous  circumstances  to  those  in 
which  the  patellar-tendon  reaction  is  exaggerated,  and  conse- 
quently often  afford  valuable  aid  in  diagnosis. 

§  84.  Trepidation  of  Extremities — Spinal  Epilepsy. — The 

VOL.  L  M 


178  ELEMENTAEY  AFFECTIONS   OF 

paroxysms  of  violent  tremulous  movements  which  occur  in  the 
lower  extremities  in  certain  affections  of  the  spinal  cord,  and 
which  Brown-Sdquard  named  Spinal  Epilepsy,  from  a  fancied 
similarity  to  an  epileptic  convulsion,  are  of  a  compound  nature. 
These    paroxysms    occur  in   chronic   diseases    implicating   the 
pyramidal  tracts,  no  matter  whether  the  latter  are  primarily  or 
secondarily  attacked,  and  consequently  they  appear  under  the 
same    general    circumstances    as    exaggerated    knee-jerk    and 
ankle   clonus.      The   tremulous   movements   indeed   appear  to 
be  caused  by  combined  contractions  induced  by  stimulation  of 
some  of  the  superficial  and  deep  reflexes  of  the  extremities.     A 
painful  cutaneous  impression,  such  as  is  caused  by  pinching  a 
portion  of  the  skin,  or  even  a  strong  pinch  of  the  tendo- Achilles, 
causes  reflex  contractions  of  the  muscles  of  the  lower  extremities, 
implicating  both   limbs.     The  primary  contractions  appear  to 
predominate  in  the  flexors,  but  when  the  anterior  flexors  of  the 
leg  contract  dorsal  flexion  of  the  foot  is  produced,  which  in  its 
turn  stretches  the  Achilles-tendon  and  causes  ankle  clonus ;  and 
these  actions  and  reactions  reverberating  for  a  time  through  all 
the  muscles,  the  lower  extremities  are  maintained  in  a  state  of 
trepidation,  which  may  be  so  violent  as  to  shake  the  bed  on 
which  the  patient  reposes.     This  tremor  may  be  provoked  not 
only  by  a  painful  impression  but  by  the  voluntary  efforts  of  the 
patient  to  raise  himself  in  bed,  and  especially  by  all  attempts  at 
locomotion.     The  most  violent  tremors  of  this  kind  which  I  ever 
witnessed  was  in  the  case  of  a  patient  suffering  from  primary 
lateral  sclerosis.     The  attempts  of  the  patient  to  get  on  the  night 
chair  were  attended  with  tremulous  movements  of  the  lower 
extremities  so  strong  as  to  shake  his  body  to  such  an  extent  that 
he  had  to  grasp  surrounding  objects  firmly  with  both  hands  to 
prevent  himself  from  being  suddenly  thrown  on  the  floor. 

If,  while  these  tremulous  movements  are  proceeding,  the  toes 
of  one  foot  be  grasped  by  the  hand  and  brought  suddenly  and 
powerfully  into  plantar  flexion,  the  muscles  immediately  relax 
and  the  tremors  cease  for  a  time. 

Paradoxical  Contraction. — Attention  has  been  drawn  by 
WestphaP  to  a  curious  phenomenon,  which  may  be  regarded 

»  Westphal  (C).  "  Ueber  eine  Art  paradoxer  Muskelcontraction."  Arch.  f. 
Psychiat.    Berl.    Bd.  X.,  1879-80,  p.  243. 


INDIVIDUAL  MOTOR  MECHANISMS.  179 

as  the  opposite  of  the  tendon-reflex  contraction  of  the  muscle. 
It  consists  in  the  contraction  of  a  muscle  induced  by  suddenly 
approximating  its  points  of  origin  and  insertion.  The  curious 
circumstance  that  a  sudden  relaxation  of  a  muscle  causes 
it  under  certain  circumstances  to  contract  has  led  Westphal  to 
name  this  phenomenon  paradoxical  contraction.  This  symptom 
is  best  studied  in  the  tibialis  anticus,  which  may  in  certain 
diseases  of  the  central  nervous  system  be  made  to  contract  by 
producing  sudden  or  sometimes  a  gradual  dorsal  flexion  of  the 
foot.  When  the  patient  is  laid  on  his  back  in  bed,  and  the 
muscles  are  relaxed,  especially  if  they  be  paralysed,  the  feet 
occupy  the  position  of  extension  or  plantar  flexion.  If  dorsal 
flexion  of  one  foot  be  now  produced,  the  tibialis  anticus,  under 
certain  circumstances,  contracts,  its  tendon  becomes  prominent, 
and  the  foot  is  maintained  for  some  minutes,  sometimes  even  as 
long  as  twenty-seven  minutes,  in  the  position  of  dorsal  flexion 
and  adduction.  When  the  muscle  is  made  to  contract  by  direct 
or  indirect  excitation  or  by  voluntary  effort,  the  foot  may  remain 
in  a  state  of  dorsal  flexion  long  after  the  stimulus  has  ceased  to 
act,  and  a  constant  current  passed  through  it  does  not  produce 
relaxation.  Distinct  resistance  is  also  offered  to  the  passive  pro- 
duction of  plantar  flexion.  After  a  variable  length  of  time  the 
muscle  relaxes,  either  gradually  and  continuously,  or  with  several 
intermissions,  and  the  foot  falls  by  its  own  weight  to  the  position 
of  plantar  flexion.  The  paradoxical  contraction  sometimes  ex- 
tends to  the  extensor  communis  digitorum  and  extensor  brevis 
pollicis.  In  one  case  observed  by  Westphal,  the  biceps  femoris 
was  seen  to  contract  on  the  leg  being  suddenly  flexed  on  the 
thigh.  This  kind  of  contraction  may  be  present  when  the  tendon 
reflexes  are  absent  or  normal,  and  probably  also  when  they  are 
slightly  exaggerated ;  but  the  presence  of  distinct  ankle  clonus 
will,  of  course,  prevent  the  foot  from  becoming  fixed.  The 
phenomenon  may  also  be  observed  when  the  cutaneous  sensi- 
bility of  the  lower  extremities  is  normal  or  lowered,  and  in  the 
absence  of  any  excess  of  the  cutaneous  reflex  excitability.  Para- 
doxical contraction  is  generally  associated  with  paresis  of  the 
lower  extremities,  but  a  spastic  rigidity  of  the  muscles  is  never 
present,  although  a  slight  degree  of  resistance  may  be  felt  to 
passive  movements  of  the  leg  and  foot.      This  form   of  con- 


180  ELEMENTARY  AFFECTIONS   OF 

traction  may  extend  to  the  muscles  of  the  upper  extremities, 
and  in  a  case  observed  by  Westphal,  in  which  some  of  them 
were  affected,  a  certain  amount  of  rigidity  subsequently 
appeared  in  the  muscles  of  both  upper  and  lower  extremities. 
It  is  a  remarkable  circumstance  that  the  paradoxical  contraction 
occurs  in  muscles  like  the  tibialis  anticus,  which  do  not  readily 
contract  when  their  tendons  are  struck  ;  and,  conversely,  the 
paradoxical  contraction  has  never  been  observed  in  muscles  like 
the  quadriceps  femoris,  which  manifest  readily  the  ten  don -reflex 
contraction.  Whether  the  paradoxical  contraction  is  caused  by 
reflex  or  direct  excitation  is  not  known.  This  phenomenon  is 
sometimes  a  symptom  of  locomotor  ataxia,  but  probably  never  of 
uncomplicated  cases  of  the  disease.  Its  presence  may,  perhaps, 
be  regarded  as  a  sign  that  the  lesion  in  the  posterior  columns  is 
extending  to  the  lateral  columns,  and  that  the  paralytic  stage  of 
the  disease  is  approaching.  This  contraction  has  also  been 
observed  by  Westphal  in  paralysis  agitans,  and  in  a  case  of 
hsematomyelia  under  my  care,  in  which  both  lower  extremities 
were  completely  paralysed,  paradoxical  contraction  was  readily 
induced  in  the  tibialis  anticus  of  the  right,  but  not  in  that  of 
the  left  leg.  The  right  leg  remained  permanently  paralysed,  but 
the  left  recovered. 

ELEMENTARY  AFFECTIONS   OF  THE  AUTOMATIC    MECHANISM 
OF  THE  MUSCLES  OF  EXTERNAL  RELATION. 

The  groups  of  symptoms  which  may  be  included  under  auto- 
matic affections  of  the  muscles  of  external  relation  cannot  be 
distinctly  separated  from  the  reflex  and  voluntary  affections  of 
those  muscles.  There  are,  however,  disturbances  of  muscular 
adjustments,  in  which  both  the  simple  reflex  actions  of  the 
spinal  cord,  the  sensory  mechanism,  and  the  efferent  or  voluntary 
nervous  mechanism  are  normal,  and  yet  in  which  complex  mus- 
cular adjustments  either  are  effected  in  spite  of  all  voluntary 
efforts  to  prevent  them,  or  fail  to  be  effected  in  spite  of  voluntary 
efforts  to  accomplish  them.  It  is  such  movements  as  these 
which  are  meant  to  be  included  under  the  name  of  Automatic 
Kinesioneuroses  of  the  muscles  of  external  relation.  These 
movements  are  in  all  probability  co-ordinated  in  the  cerebellum 
and  basal  ganglia  of  the  cerebnira.     Motor  disturbances  of  this 


INDIVIDUAL   MOTOR  MECHANISMS.  181 

nature  may  be  caused  by  disease  of  some  of  the  nervous  centres 
or  of  some  of  the  conducting  paths ;  but  the  most  useful  and 
practical  classification  is  that  which  divides  them  into  affections 
of  the  peripheral,  spinal,  or  encephalic  apparatus. 

§  85.  Peripheral  Automatic  Disturbances. 

Disorder  of  Labyrinthine  Impressions. — Disease  of  the 
peripheral  nerves  generally  involves  either  the  sensory  or  volun- 
tary motor  fibres,  or  both  together,  so  that  disorder  of  muscular 
co-ordination  becomes  thus  obscured  by  the  more  important,  or 
at  least  more  prominent,  disorder  of  the  conscious  muscular 
adjustments.  It  would  appear,  however,  that  the  seventh  pair  of 
cranial  nerves  contains  afferent  fibres  which  are  not  subservient 
to  the  conduction  of  sensory  impressions,  and  yet  disease  of 
which  gives  rise  to  phenomena  of  motor  inco-ordination. 

When  the  horizontal  membranous  semicircular  canal  of  the 
internal  ear  is  cut  through  in  a  pigeon,  the  bird  is  observed  to  be 
continually  moving  its  head  from  side  to  side,  especially  during 
attempts  at  locomotion.  If  one  of  the  vertical  canals  be  cut 
through,  the  movements  are  up  and  down  ;  and  the  condition  is 
exaggerated  when  the  canals  of  both  sides  have  been  operated 
upon.  If  the  bird  be  thrown  into  the  air,  it  flutters  and  falls 
down  in  a  helpless  and  confused  manner,  and  every  movement 
which  it  attempts  to  perform  is  disorderly  and  fails  of  its  purpose. 
The  want  of  co-ordination  is  not  due  to  loss  of  auditory  sensa- 
tions, since  the  animal  can  hear  perfectly  well,  although  similar 
phenomena  may  also  be  caused  by  lesion  of  the  auditory  trunk, 
section  of  which,  in  the  frog  and  mammals,  produces  inco- 
ordination of  movements.  Similar  symptoms  are  also  observed 
in  man  in  disease  of  the  semicircular  canals  or  of  the  internal  ear ; 
an  affection  which  will  be  subsequently  described  as  Meniere's 
disease. 

§  86.  Spinal  Automatic  Disturbances. — Ataxia  is  a  very 
characteristic  kind  of  motor  inco-ordination,  observed  in  diseases 
of  the  spinal  cord,  and  constituting  the  most  prominent  feature 
of  locomotor  ataxia.  It  is  characterised  by  inability  to  make 
combined  or  complicated  movements  with  certainty  and  pre- 
cision, and  in  advanced  cases  all  movements  requiring  intricate 


182  ELEMENTARY  AFFECTIONS  OP 

and  delicately-balanced  muscular  adjustments  become  impossible. 
The  motor  inco-ordination  usually  presents  itself  in  the  most 
marked  manner  during  station  and  locomotion.  When  the 
patient  assumes  the  erect  posture,  the  muscles  of  the  calves  of 
the  legs,  those  of  the  front  of  the  thigh,  and  the  erector-spinse, 
may  be  observed  in  a  state  of  strong  tonic  contraction.  Partly 
in  consequence  of  these  contractions,  aud  partly  in  consequence 
of  a  loss  of  harmony  in  the  strength  of  the  contractions  of  the 
various  groups,  it  is  necessary  for  the  patient,  even  in  the  early 
stages  of  the  affection,  to  support  himself  by  the  aid  of  a  staff, 
or  even  by  the  aid  of  one  in  each  hand ;  while  to  prevent  the 
body  being  dragged  backwards  by  the  strong  contractions  of  the 
erector-spinse,  it  is  maintained  by  voluntary  effort  slightly  flexed 
on  the  thighs. 

All  the  movements  required  in  walking  are  much  exaggerated 
in  this  affection.  In  order  to  advance  the  foot  which  is  about  to 
become  "  passive,"  the  pelvis  is  rotated  vertically  to  an  unusual 
extent  by  a  voluntary  contraction  of  the  abductors  of  the  oppo- 
site thigh ;  but  instead  of  the  various  segments  of  the  passive  leg 
being  now  flexed  upon  one  another,  so  as  to  admit  of  the  usual 
pendulum  movement  of  the  leg,  the  limb  is  projected  more  or 
less  violently  forwards  or  forwards  and  outwards,  the  heel  being 
the  last  part  of  the  foot  which  leaves  the  ground,  and  when  the 
foot  is  again  placed  on  the  ground  the  heel  is  brought  down 
with  a  forcible  thump.  The  phenomena  differ  greatly  according 
to  the  degree  of  the  ataxia.  In  slight  cases  the  various  seg- 
ments of  the  passive  leg  may  be  slightly  flexed  on  one  another 
during  the  forward  movement,  so  that  the  heel  may  even  be 
raised  off  the  ground  before  the  toe ;  but  even  in  slight  cases 
the  heel  is  brought  down  to  the  ground  with  a  certain  degree 
of  force.  In  the  more  severe  cases  the  movements  of  the  legs 
are  exaggerated,  impulsive,  and  jerking,  often  made  in  a  wrong 
direction,  and  always  with  a  degree  of  force  quite  dispropor- 
tionate to  the  adjustment  to  be  effected.  The  want  of  harmony 
between  the  degrees  of  strength  of  the  various  muscular  con- 
tractions necessary  for  normal  locomotion  is  much  increased 
when  the  patient  endeavours  to  walk  in  the  dark,  or  closes  his 
eyes.  As  the  disease  advances  it  becomes  necessary  for  the 
patient  to  exercise  an  increased  control  with  his  eyes  over  the 


INDIVIDUAL   MOTOR  MECHANISMS.  183 

movements  of  his  legs,  so  that  during  locomotion  the  eyes  are 
kept  constantly  directed  to  the  ground.  During  the  whole  of 
this  time  there  is  no  loss  of  voluntary  power.  When  the  patient 
is  lying  down  he  can  perform  all  the  simple  movements  of  the 
legs  with  ease,  and  probably  with  even  more  than  normal  force, 
since  the  muscular  masses  of  the  legs  are  not  unfrequently 
increased  in  size  in  the  earlier  stages  of  the  affection.  But  even 
in  the  recumbent  posture  the  patient  is  unable  to  perform  any 
complicated  movement.  If  he  is  asked,  for  instance,  to  touch 
an  object  with  the  toes,  the  mark  is  generally  missed.  In 
advanced  cases  this  uncertainty  extends  to  the  simple  move- 
ments, so  that  on  attempting  even  to  raise  the  leg  it  is  jerked 
hither  and  thither,  and  often  in  a  totally  different  direction  to 
the  one  intended. 

Locomotor  ataxia  is  caused  by  disease  of  tlie  posterior  columns  of  the 
spinal  cord ;  and  as  the  fibres  of  the  posterior  roots  of  the  nerves  are 
usually  implicated,  the  ataxic  symptoms  are  generally  associated  with 
various  sensory  disturbances,  and  some  authors  maintain  that  the  motor 
inco-ordination  is  due  to  disease  of  the  sensory  apparatus.  Against  this 
view,  it  is  urged  that  there  frequently  exists  a  great  disproportion  between 
the  intensity  of  the  sensory  disturbance  and  the  degree  of  ataxia ;  cases 
being  recorded  in  which  the  ataxic  symptoms  were  well  marked,  while 
the  sensory  disorders  were  slight  or  absent ;  while  other  cases  manifest 
severe  sensory  disorders,  probably  as  long  as  twenty  years  prior  to  the 
appearance  of  the  ataxia.  Other  authors  appear  to  attribute  the  ataxic 
symptoms  to  disease  of  the  cerebro-spinal  efferent  system,  which  causes  an 
abnormal  strength  of  nervous  imj)ulses  to  be  sent  to  each  of  the  muscles 
engaged  in  effecting  complicated  muscular  adjustment.  My  own  opinion, 
however,  is  that  the  ataxic  symptoms  are  caused  by  disease  of  the  cerebello- 
afferent  conducting  paths  in  the  spinal  cord.  The  undue  amount  of  tonic 
contraction  of  the  muscles  of  the  calf,  front  of  the  thigh,  and  of  the  erector- 
spinse,  in  the  early  stages  of  the  disease,  would  appear  to  indicate  that  at 
that  time  the  irritability  of  the  cerebello-afferent  fibres  of  the  cord  is 
increased  ;  while  in  the  later  stages  of  this  affection,  although  there  is  no 
cerebral  paralysis,  yet  there  is  cerebellar  paralysis,  and  the  consequent  aboli- 
tion of  the  tonic  muscular  contractions  regulated  through  the  cerebellum, 
overthrows  the  balance  of  the  delicate  muscular  adjustments  necessary  for 
the  maintenance  of  the  erect  posture  and  for  locomotion  ;  the  muscles  of 
the  trunk  and  limbs  are  not  maintained  in  that  state  of  balanced  and  con- 
tinuous contraction  which  will  enable  the  alternate  contractions  regulated 
through  the  cerebrum  to  act  efficiently  and  harmoniously. 

Brauch-Bomherg   Symptom. — A    symptom    that   is   closely 


184  ELEMENTARY  AFFECTIONS  OF 

allied  to  ataxia  is  one  which,  from  the  observers  who  first 
described  it,  is  often  called  the  Brauch -Romberg  symptom.  If 
a  patient  suffering  from  ataxy  be  made  to  stand  with  the  feet 
close  together  so  that  they  touch  along  the  whole  length  of  their 
inner  margins,  and  if  the  patient  be  now  asked  to  close  his  eyes, 
he  immediately  begins  to  sway  from  side  to  side ;  and  in  severe 
cases  the  patient  totters,  and  would  instantly  fall  unless  he  open 
his  eyes  or  be  supported.  This  symptom  is  also  usually  associated 
with  diminution  of  the  various  forms  of  sensibility  of  the  skin, 
muscles,  and  joints,  and  some,  probably  most,  authors  think  that 
this  symptom  at  least  is  due  to  loss  of  the  sensory  control  of  the 
lower  extremities,  a  loss  which  may  be  partly  supplied  by  the 
use  of  the  eyes,  but  which  immediately  leads  to  disorderly  mus- 
cular contraction  when  the  eyes  are  closed.  In  a  case  under  my 
care,  however,  the  swaying  movements  on  closing  the  eyes  were 
extremely  well  marked,  being  out  of  proportion  to  the  degree 
of  ataxia,  yet  sensory  disorders  were  almost  entirely  absent 
in  the  lower  extremities.  For  my  own  part  I  think  that  these 
swaying  movements  are  of  the  same  nature  as  the  ataxia,  and 
that  the  former  are  caused  by  disease  of  the  same  kind  of  fibres 
as  the  latter,  although  it  is  probable  that  the  individual  fibres 
implicated  in  both  instances  may  not  be  the  same,  since  the 
swaying  movement  and  ataxia  are  not  always  present  in  propor- 
tionate degree. 

§  87.  Encephalic  Automatic  Disturbances. 

Disease  or  injury  of  the  cerebellum  and  its  connections  gives 
rise  to  the  most  pronounced  phenomena  of  motor  inco-ordination. 
Flourens  observed  that  when  a  small  portion  of  the  cerebellum 
was  removed  from  a  pigeon,  the  animal's  gait  became  unsteady 
and  disorderly ;  and  removal  of  the  whole  organ  was  followed  by 
a  total  loss  of  co-ordination.  Similar  experiments  repeated  in 
other  animals  have  led  to  essentially  the  same  results;  and  it 
has  been  found  that  la,teral  lesions  and  incisions  produce  a  greater 
result  than  median  incisions.  Similar  motor  disturbances  have 
been  observed  in  man  in  tumours  and  other  lesions  of  the 
cerebellum. 

(1)  Reeling. — The  well-known  gait  of  a  drunken  man  is  called 
reeling.     It  consists  essentially,  as  Dr.  Hughlings  Jackson  has 


INDIVIDUAL  MOTOR  MECHANISMS.  185 

pointed  out,  of  swaying  of  the  trunk  from  back  to  front  and  from 
side  to  side ;  and  depends  upon  paresis  of  the  tonic  contractions 
of  the  muscles  of  the  trunk,  which  maintain  the  erect  posture. 
"  The  legs  act  erratically,"  says  Dr.  Hughlings  Jackson  ;  "  but,  in 
an  early  stage,  they  are  blameless.  They  act  erratically  because 
they  have  to  run  after  the  trunk,  to  prop  it  up  in  its  various 
over-inclinings."  ^ 

(2)  Cerebellar  Rigidity. — This  form  of  rigidity  is  found 
associated  with  tumour  of  the  middle  lobe  of  the  cerebellum 
(Hughlings  Jackson).  The  spinal  muscles  are  first  affected, 
drawing  back  the  head  and  curving  the  spine,  but  after  a  time 
the  legs  and  arms  become  rigid. 

(3)  Cerebellar  Tetanic  Seizures. — Tumour  of  the  middle  lobe 
of  the  cerebellum  also  gives  rise  to  attacks  of  tonic  spasm  similar 
to  those  of  ordinary  surgical  tetanus.  Dr.  Hughlings  Jackson 
thinks  that  the  rigidity  in  cerebellar  disease  is  due  to  unan- 
tagonised  cerebral  influx ;  being  thus  the  converse  of  the  late 
rigidity  of  hemiplegics,  the  latter  of  which,  he  thinks,  is  due  to 
unantagonised  cerebellar  influx.  The  tetanic  seizures  in  cere- 
bellar disease,  Dr.  Jackson  thinks,  are  due  to  a  discharge  from 
the  cortex  of  the  cerebellum;  just  as  unilateral  epileptoid 
seizures  are  due  to  a  discharge  from  the  cortex  of  the  brain. 

(4)  Compulsory  or  Forced  Movements — Co-ordinate  Cramps. 
In  experimental  injury  to  various  parts  of  the  medulla,  pons, 
and  crura  cerebri,  what  are  described  as  forced  movements  are 
frequently  observed.  It  is  probable  that  in  many  of  these  cases 
one  or  other  of  the  peduncles  of  the  cerebellum  has  been  injured. 
One  of  the  most  common  forms  of  these  movements  is  that  in 
which  the  animal  rolls  round  the  longitudinal  axis  of  its  own 
body.  It  generally  results  from  section  of  one  of  the  crura 
cerebri  or  unilateral  section  of  the  pons,  but  has  also  been- 
observed  after  injury  to  the  medulla  oblongata  and  corpora 
quadrigemina.  Another  form  is  that  in  which  the  animal  con- 
tinually moves  round  and  round  in  a  circle,  this  circus  movement 
being  executed  sometimes  towards  and  sometimes  away  from 
the  injured  side.  Phenomena  of  essentially  the  same  character, 
although  not  carried  to  the  same  extent,  are  observed  in  man  as 
the  result  of  disease,  as,  for  example,  what  will  be  immediately 

'  The  British  Medical  Journal,  February  7,  1880,  p.  197. 


186  ELEMENTARY  AFFECTIONS  OF 

described  as  conjugate  deviation  of  the  eyes  in  certain  cases  of 
apoplexy.  In  another  form  of  forced  movement  the  animal 
rotates  round  the  transverse  axis  of  the  body,  tumbling  head 
over  heels  in  a  series  of  somersaults.  This  variety  has  been 
observed  after  injury  to  the  corpora  quadrigemina  and  corpora 
striata.  Nothnagel  has  found  that  after  injection  of  chromic  acid 
into  a  limited  portion  of  the  corpus  striatum,  which  he  has  called 
the  nodus  cursorius,  in  rabbits,  the  animal  runs  in  a  straight 
line  either  backwards  or  forwards  until  stopped  by  an  obstacle. 
It  will  be  observed  that  some  of  these  forced  movements  occur 
after  injuries  which  appear  limited  to  the  cerebral  hemispheres; 
but  it  must  be  remembered  that  conducting  paths  must  exist 
between  the  cerebellum  and  the  cortex  of  the  cerebrum ;  and  it 
is  very  probable  that  the  central  lesion  in  these  cases  really 
injures  these  conducting  paths.  It  may  therefore  be  said  with  a 
great  deal  of  probability  that  in  many  forms  of  compulsory 
movements,  in  reeling,  ataxia,  and  other  symptoms  of  motor 
inco-ordination,  it  is  the  cerebello- spinal  mechanism  which  is  at 
fault;  and  that  the  functional  disturbances  are  determined 
primarily  by  disorders  of  the  tonic  muscular  contractions  by 
means  of  which  the  various  attitudes  of  the  body  are  maintained. 
Another  series  of  motor  disorders  appears  to  depend  upon 
disease  of  the  cerebro -spinal  system.  Amongst  these  may  be 
mentioned  the  peculiar  disturbances  of  locomotion  which  occur 
in  paralysis  agitans,  and  the  irregular  movements  of  chorea,  and 
various  other  disorderly  movements.  It  is  obvious  that  the 
pathology  of  these  motor  disturbances  cannot  be  satisfactorily 
discussed  at  present,  and  must  be  referred  to  the  section  devoted 
to  the  special  diseases. 

§  88.  Synkinesis. 

Under  this  term  are  generally  included  certain  involuntary 
movements  of  paralysed  parts ;  but  I  shall  extend  the  meaning 
of  the  word  so  as  to  include  also  certain  motor  anomalies  which 
occur  in  muscles  subject  to  spasm;  and,  in  addition,  I  shall 
include  certain  anomalous  movements  which  take  place  in  the 
muscles,  that,  in  health,  are  associated  in  their  actions  with  those 
primarily  affected.  There  is  certainly  nothing  in  the  derivation 
of  the  term  synkinesis  to  forbid  this  extension  of  its  meaning. 


INDIVIDUAL  MOTOK  MECHANISMS.  187 

§  89.  Associated  Movements  of  Paralysed  Parts. — In  facial 
paralysis  of  cerebral  origin,  the  muscles  of  the  paralysed  half  of 
the  face  may  occasionally  perform  the  movements  necessary  to 
changes  of  expression  in  association  with  those  of  the  opposite 
side;  although,  as  a  rule,  the  contrast  between  the  actions  of 
the  two  sides  is  rendered  all  the  more  evident  under  changes  of 
expression.  In  cases  of  hemiplegia  automatic  movements  may 
occur  in  the  paralysed  arm  when  the  patient  sneezes,  even  when 
he  is  quite  unable  to  move  the  arm  by  a  voluntary  effort ;  and 
under  the  influence  of  excitement  the  paralysed  extremities  may 
be  strongly  flexed,  while  the  unaffected  limbs  remain  passive. 
"When  the  muscles  of  the  paralysed  side  have  become  the  subject 
of  permanent  contracture,  a  movement  about  to  be  voluntarily 
performed  by  the  unaffected  extremities  may  be  initiated  by 
contraction  of  the  corresponding  muscles  of  the  opposite  side. 
This  form  of  associated  movement  is  apt  to  occur  when  the 
hemiplegia  dates  from  childhood.  In  a  man  under  my  care, 
who  was  slowly  recovering  from  right  hemiplegia,  every  effort  to 
grasp  my  hand  strongly  with  his  left  or  sound  hand  was  accom- 
panied by  flexion  of  the  fingers  of  the  partially  paralysed  hand  ; 
and,  conversely,  every  effort  to  grasp  strongly  with  the  right 
hand  was  accompanied  by  flexion  of  the  fingers  of  the  healthy 
hand.  During  slighter  efforts  both  the  paralysed  and  healthy 
hand  could  be  separately  closed  without  any  movement  occurring 
in  the  other  hand.  In  another  case  of  hemiplegia  of  old  date 
under  my  observation,  the  posterior  third  of  the  deltoid  of  the 
left  side  was  in  a  state  of  contracture,  and  the  upper  arm  was 
directed  obliquely  outwards  and  backwards.  When  the  patient 
was  at  rest  in  the  erect  posture  the  distance  between  the  elbow 
and  the  side  was  five  inches  ;  but  on  walking,  the  posterior  third 
of  the  deltoid  immediately  became  more  tense  and  prominent, 
and  the  elbow  was  projected  another  inch  aud  a  half  outwards 
and  backwards,  the  distance  between  it  and  the  side  being  then 
six  and  a  half  inches. 

In  all  these  instances,  and  many  more  of  a  similar  kind  which 
might  be  related,  the  localisation  of  the  lesion  is  such  as  to  inter- 
rupt conduction,  either  totally  or  partially,  through  the  pyramidal 
tract,  either  in  the  course  of  the  fibres  or  at  their  origin  in  the 
cortex  of  the  brain ;  while  the  connection  of  the  muscles  with 


188  ELEMENTARY  AFFECTIONS   OF 

the  spinal  cord  is  unaffected.  In  this  form  of  paralysis  the 
reflexes  often  manifest  increased  activity,  and  it  is  also  probable 
that  cutaneous  reflex  influences  may  be  conveyed  from  the  sound 
to  the  paralysed  side  through  commissural  fibres  connecting  the 
nerve  nuclei  of  the  two  sides  in  the  spinal  cord.  But  it  is 
equally  possible  that  automatic  impulses  from  the  cerebellum 
and  basal  ganglia,  and  even  cerebral  impulses  from  the  cortex  of 
the  healthy  hemisphere,  may  find  their  way  to  the  paralysed 
limbs  through  these  commissural  fibres.  But  the  whole  of  this 
subject  will  be  better  understood  when  we  describe  the  relative 
immunity  from  paralysis  manifested  by  some  muscles  in  com- 
parison with  others,  and  the  mechanism  by  which  this  result  is 
brought  about. 

§  90,  Relative  Immunity  of  Some  Muscles  from  Paralysis, 
and  their  Relative  Liability  to  Convulsion  in  Cerebral  Disease. 
It  may  be  laid  down  as  a  general  proposition  that  the  muscles 
of  one  lateral  half  of  the  body  are  regulated  from  the  cerebral 
hemisphere  of  the  opposite  side,  and  that  when  the  connection 
between  the  muscles  of  one  side  of  the  body  and  the  cortex  of 
the  opposite  hemisphere  is  severed  paralysis  of  those  muscles 
will  result ;  or,  in  other  words,  there  will  be  hemiplegia  of  the 
lateral  half  of  the  body  opposed  to  the  diseased  hemisphere. 
This  rule  is,  however,  liable  to  many  exceptions,  and  it  is  these 
exceptions  which  give  the  key  to  the  interpretation  of  the  motor 
anomalies  which  I  have  grouped  under  the  name  of  synkinesis. 

The  most  notable  exception  to  this  rule  is,  that  in  cases  of 
hemiplegia  while  some  of  the  muscles  are  liable  to  be  completely 
paralysed  others  are  only  partially  paralysed,  while  some  mani- 
fest only  a  slight  degree  of  feebleness.  In  left  hemiplegia,  for 
instance,  the  muscles  of  the  extremities  may  be  completely 
paralysed ;  but  the  muscles  of  the  trunk,  especially  those 
engaged  in  carrying  on  respiration  and  other  automatic  actions, 
almost  entirely  escape.  Two  reasons  may  be  given  for  this 
variation  in  the  degree  of  paralysis.  In  the  first  place,  the 
movements  of  respiration  are  well  organised,  they  are  regulated 
principally  from  the  medulla  oblongata,  and  are  in  large  part 
independent  of  cerebral  influence ;  while  the  more  complicated 
movements  of  the  extremities,  and  especially  those  of  the  hand, 


INDIVIDUAL  MOTOR  MECHANISMS.  189 

demand  a  relatively  larger  amount  of  voluntary  control.  The 
spinal  nuclei  of  the  muscles  of  the  extremities  must  be  there- 
fore connected  with  the  cortex  of  the  brain  by  a  much  larger 
number  of  fibres  than  are  the  respiratory  nuclei ;  and  while  the 
fibres  which  connect  the  latter  and  the  cortex  belong  to  the 
fundamental  system,  a  large  proportion  of  those  which  connect 
the  former  and  the  cortex  belong  to  the  accessory  system,  and 
are  consequently  the  more  vulnerable  of  the  two.  The  relative 
immunity  from  voluntary  paralysis  of  the  muscles  supplied  by 
the  upper  division  of  the  facial  nerve,  as  compared  with  those 
supplied  by  the  lower  division,  is  also  very  instructive  in  this 
respect.  In  hemiplegia  affecting  the  facial  nerve,  the  muscles  of 
the  mouth  and  nose,  which  are  subservient  to  facial  expression, 
become  completely  paralysed  ;  while  the  orbicular  muscle  of  the 
eyelid  and  the  occipito  frontalis  muscles  are  almost  entirely  un- 
affected. Now  the  movements  of  the  muscles  about  the  eyelids 
are  well  organised  in  animals  and  in  the  child  at  birth  ;  the 
most  important  of  these  are  reflex  in  character,  such  as  closure 
of  the  eyelids  on  irritation  of  the  conjunctiva,  and  they  are 
largely  independent  of  the  will ;  consequently,  relatively  few 
fibres  are  necessary  to  connect  their  nucleus  in  the  medulla 
with  the  cortex  of  the  brain,  and  even  these  fibres  must  belong 
to  the  fundamental  system.  But  the  movements  of  facial 
expression  are  not  well  organised  in  animals  or  in  the  child  at 
birth,  while  in  the  adult  man  they  are  largely  under  voluntary 
control ;  hence  a  relatively  larger  number  of  fibres  must  connect 
their  nucleus  in  the  medulla  with  the  cortex  of  the  brain,  and  a 
large  proportion  of  these  fibres  must  belong  to  the  accessory 
system.  It  may,  indeed,  be  laid  down  as  a  general  rule  that 
movements  which  are  well  organised  in  the  human  infant  at 
birth,  and  which  man  possesses  in  common  with  a  large  number 
of  the  lower  animals,  are  represented  in  the  pyramidal  tract  by 
comparatively  few  fibres,  and  that  these  are  completely  developed 
at  birth,  and  therefore  belong  to  the  fundamental  system.  On 
the  contrary,  the  movements  which  are  acquired  by  man  after 
birth,  and  which  differentiate  him  from  the  lower  animals,  are 
represented  in  the  pyramidal  tract  by  a  relatively  large  number 
of  fibres  that  either  do  not  exist  at  birth  or  exist  only  in  a  rudi- 
mentary condition,  and  consequently  belong  to  the  accessory 


190  ELEMENTARY  AFFECTIONS   OF 

system.  It  would  appear,  therefore,  that  both  the  relatively- 
small  number  of  the  fundamental  fibres  of  the  pyramidal  tract 
and  their  better  organisation  must  render  them  less  liable  to 
disease  than  the  accessory  fibres,  and  this  explains  to  some 
extent  the  relative  immunity  from  paralysis  of  those  muscles 
which  are  engaged  in  effecting  the  earlier  organised  movements 
of  the  body. 

But  the  second  reason  for  the  relative  immunity  of  certain 
muscles  from  voluntary  paralysis  is  even  more  important  than 
the  first.  Dr.  Broadbent^  was  the  first  to  draw  attention  to  the 
fact  that  the  muscles  which  remain  comparatively  unaffected  by 
paralysis  in  hemiplegia  are  those  which  are  associated  in  their 
actions  with  the  corresponding  muscles  of  the  opposite  side,  as 
the  muscles  of  respiration ;  while  the  muscles  that  suffer  most 
from  paralysis  are  those  engaged  in  effecting  movements  which 
are  quite  independent  of  the  movements  of  the  opposite  side 
of  the  body,  as  the  muscles  of  the  hand.  Dr.  Broadbent 
also  further  conjectured  that  the  muscles  which  are  associated 
with  corresponding  muscles  on  the  opposite  side  in  their 
action  are  innervated  from  both  cerebral  hemispheres,  so 
that  severance  of  the  connection  between  the  spinal  nuclei  of 
these  muscles  and  the  cortex  of  one  hemisphere  still  leaves  the 
connection  with  the  cortex  of  the  other  hemisphere  intact.  He 
has  suggested  that  the  connection  with  the  two  hemispheres  is 
usually  effected  by  means  of  spinal  commissural  fibres.  In 
Fig.  14,  for  instance,  df,  representing  the  spinal  nuclei  of  the 
dorsal  nerves  of  the  left  side,  is  connected  with  the  cortex  of 
the  opposite  side  by  fibres  (5  5)  which  ascend  in  the  pyramidal 
tract ;  and  also  with  that  of  the  same  side  through  c'",  the  com- 
missural fibres  which  connect  the  two  spinal  nuclei,  and  5'  5',  the 
fibres  connecting  the  right  nuclei  with  the  cortex.  Suppose  now 
that  the  fibre  5  5  is  ruptured,  and  the  nucleus  d'  is  thus  severed 
from  the  cortex  of  the  opposite  hemisphere,  which  usually  controls 
its  function,  it  can  still  obtain  impulses  from  the  cortex  of  the 
same  side  through  h'  5',  d,  and  c"\  When,  however,  the  muscles 
of  opposite  sides  act  independently  of  each  other,  such  as  those  of 
the  right  and  left  hands,  commissural  fibres  are  not  established 
between  their  nerve  nuclei.     In  the  nucleus  (a)  of  the  right 

»  Broadbent  (W.  H.).    British  and  Foreign  Mea.-Chir.  Review,  1866,  p.  477. 


INDIVIDUAL  MOTOR  MECHANISMS. 


191 


upper  extremity,  as  repre- 
sented in  the  figure,  rupture 
of  fibre  6'  severs  the  con- 
nection with  the  cortex  of 
the  opposite  side,  and  no 
channel  is  established  by 
means  of  which  it  can  obtain 
impulses  from  the  cortex  on 
the  same  side.  Dr.  Broad- 
bent  has  happily  called*  this 
principle  the  "bilateral  as- 
sociation of  the  nerve  nuclei 
of  muscles  bilaterally  asso- 
ciated in  their  actions." 

The  effect  which  this  bi- 
lateral fusion  of  the  spinal 
nerve  nuclei  of  various 
nerves  produces  in  certain 
spasmodic  affections  is  as 
striking  as  that  produced 
by  it  in  hemiplegia.  In  uni- 
lateral chorea,  for  instance, 
while  the  spasmodic  action  is 
limited  to  one  side  in  the  ex- 
tremities and  lower  muscles 
of  the  face,  it  extends  to 
the  muscles  of  both  sides 
of  the   trunk   and   of   the 


Fig.  14. 


Fig.  14.— C,  C,  cortex  of  right  and  left  cerebral  hemispheres  respectively;  1,  2, 
3,  4,  5,  6,  fibres  of  the  pyramidal  tract  uniting  C,  the  cortex  of  the  right 
hemisphere,  and  r',  e'r,  v',  a',  d',  I',  the  respective  spinal  nuclei  of  the  internal 
rectus,  and  the  external  rectus  muscles  of  the  eye,  the  muscles  of  articulation 
and  vocalisation,  those  of  the  upper  extremity,  the  dor.sal  muscles,  and  these 
of  the  lower  extremity,  all  of  the  left  side;  1',  2',  3',  4',  5',  6',  fibres  of  the 
pyramidal  tract,  connecting  the  cortex  of  the  left  hemisphere  with  r,  er,  v,  a,  d,  I, 
the  spinal  nuclei  of  the  right  side  corresponding  to  those  already  enumerated 
on  the  left  side ;  c,  c,  fibres  of  the  corpus  callosum  uniting  identical  regions  of 
the  two  hemispheres ;  c',  commissural  fibres  connecting  the  spinal  nucleus  of 
the  internal  rectus  muscle  of  one  eye  with  that  of  the  external  rectus  muscle  of 
the  opposite  eye ;  c",  those  connecting  the  spinal  nuclei  of  the  muscles  of  vocalisa- 
tion and  articulation  of  the  two  sides ;  c'",  those  connecting  the  special  nuclei 
of  the  muscles  of  the  trunk ;  c^,  those  connecting  the  spinal  nuclei^  of  the 
posterior  extremity  of  one  side  with  the  anterior  extremity  of  the  opposite  side. 
The  arrows  indicate  the  direction  of  the  conduction. 


192  ELEMENTARY  AFFECTIONS  OF 

eyelids  and  eyebrows,  these  being  muscles  which  are  habitually 
associated  in  their  actions.  This  rule  is  also  true  with  respect 
to  other  forms  of  convulsion,  so  that  in  heTuispasm  the  muscles 
which  are  habitually  associated  in  their  actions  are  affected 
on  both  sides ;  while  in  hemiplegia  these  muscles  are  com- 
paratively preserved  from  paralysis.  The  reason  of  this  is  so 
plain  that  it  is  scarcely  necessary  to  add  another  word  by  way 
of  explanation.  Suppose  that  excessive  impulses  are  sent  down 
from  the  cortex  of  the  brain  through  the  fibres  6'  and  5",  the 
former  will  reach  a  and  pass  out  through  hn  to  the  muscles  of 
the  arm  on  the  opposite  side ;  while  the  latter  will  reach  d  and 
pass  both  through  dn  and  c'",  d',  and  dn'  to  reach  the  muscles  of 
the  trunk  on  both  sides.  But  the  muscles  which  are  habitually 
associated  in  their  actions  are  not  always  symmetrically  placed 
on  the  two  sides  of  the  organism,  nor  are  their  actions  always 
analogous.  It  is  only  necessary  that  their  actions  should  concur 
to  produce  a  definite  result ;  and  the  commissural  fibres  often 
connect,  not  two  nerve  nuclei  on  the  same  spinal  level,  but 
nuclei  at  different  levels,  thus  forming  an  oblique  crossed 
connection  as  in  {Fig.  14,  c^). 

§  91.  Conjugate  Deviation  of  the  Eyes,  and  Rotation  of  the 
Head  and  Neck. — The  actions  of  the  external  rectus  of  one  eye 
and  of  the  internal  of  the  other  is  a  good  example  of  muscles 
having  quite  opposite  actions  and  yet  concurring  to  produce  a 
harmonious  result.  It  is  evident  that  if  commissural  connections 
exist  anywhere  they  must  exist  between  the  nucleus  of  the  sixth 
nerve  of  one  side  and  the  portion  of  the  nucleus  of  the  third 
nerve  which  presides  over  the  action  of  the  internal  rectus  of  the 
opposite  eye ;  and  as  these  nuclei  are  placed  at  different  levels 
in  the  pons  and  crura,  the  connection  between  them  must  be 
oblique  and  crossed.  In  Fig.  14,  let  r  and  /  represent  respec- 
tively the  nucleus  of  the  portion  of  the  third  nerves  (3u  and 
^n')  supplied  to  the  right  and  left  internal  recti,  and  er  and  er' 
be  respectively  the  nuclei  of  the  right  and  left  sixth  nerves 
{Qn  and  Qn')\  while  c'  represents  the  crossing  of  the  com- 
missural fibres.  The  external  rectus  of  one  eye  and  the  internal 
of  the  other  eye  acting  simultaneously  rotate  both  eyes  so  as  to 
direct  the  axes  of  vision  to  lateral  objects.     When  the  object  is 


INDIVIDUAL  MOTOR  MECHANISMS.  193 

placed  to  the  right  it  is  manifest  that  the  right  eye  is  in  a  better 
position  than  the  left  to  catch  the  first  glimpse  of  it,  hence 
the  external  rectus  which  rotates  the  right  eye  outwards 
takes  the  lead  in  the  action.^  But  the  internal  rectus  of  the 
opposite  side  rotates  at  the  same  time  the  left  eye  inwards ;  and 
to  effect  this  movement  it  will  be  a  clear  gain  of  time,  as  well  as 
economy  of  force,  if  it  were  to  receive  its  impulses  to  action 
through  the  short  commissural  fibres  which  connect  the  two 
nuclei,  and  not  from  the  cortex  of  the  cerebrum  of  the  opposite 
side.  When,  therefore,  the  eyes  are  directed  by  a  voluntary 
effort  to  the  right,  the  impulse  to  action  may  be  supposed  to  come 
from  the  cortex  of  the  brain  (C)  on  the  opposite  side,  to  pass 
out  through  the  fibres  (2')  of  the  pyramidal  tract  which  connect 
the  cortex  with  the  nucleus  of  the  sixth  nerve  (er'),  and  then  to 
pass  on  through  the  commissural  fibres  {c')  to  the  part  of  the 
nucleus  (r)  of  the  opposite  third  nerve  concerned  in  the  action. 
According  to  this  statement,  therefore,  in  directing  the  eyes 
laterally,  say  to  the  right,  both  the  right  external  rectus  and  the 
left  internal  rectus  receive  the  impulse  to  action  from  the  cortex 
of  the  left  hemisphere,  the  impulses  of  the  nucleus  of  the  third 
nerve  being  received  through  the  commissural  fibres  which  con- 
nect it  with  the  nucleus  of  the  sixth  nerve  of  the  opposite  side. 
So  far  we  have  only  spoken  of  the  two  recti  muscles,  but  when 
these  muscles  are  contracting  so  that  the  eyes  are  directed 
laterally,  the  muscles  which  rotate  the  head  also  become  con- 
tracted in  such  a  way  that  the  head  is  turned  in  the  same 
direction  as  the  eyes,  this  movement  being  frequently  observed 
when  a  man  looks  over  his  shoulder.  Kotation  of  the  head,  say 
to  the  right,  is  produced  mainly  by  contraction  of  the  right  in- 
ferior oblique  muscle  of  the  neck,  although  the  left  sterno- 
mastoid,  and  probably  other  muscles,  co-operate  in  the  move- 
ment, and  these  muscles  also  receive  their  voluntary  impulses  to 
action  through  commissural  fibres  which  connect  their  nerve 
nuclei  with  the  nucleus  of  the  sixth  nerve  of  the  right  side. 
According  to  this  supposition,  when  a  strong  impulse  is  sent 
from  the  left  cortex  (C)  of  the  brain  through  the  fibres  (2') 

•  Broadbent  (W.  H.).  "On  conjugate  deviation  of  the  head  and  eyes  as  a 
symptom  in  cerebral  haemorrhage  and  other  affections."  The  Lancet,  Vol.  II., 
1875,  p.  861. 

VOL.  I.  N 


194  ELEMENTARY  AFFECTIONS   OF 

which  connect  it  with  the  nucleus  (er)  of  the  sixth  nerve  of  the 
opposite  side,  these  impulses  will  also  pass  through  commissural 
fibres  to  the  nuclei  of  the  nerves  which  supply  the  internal 
rectus  and  sterno-cleido-mastoid  muscles  of  the  opposite  side, 
and  of  the  inferior  oblique  muscle  of  the  neck  of  the  same  side ; 
and  the  eyes  and  head  will  consequently  be  strongly  rotated  to 
the  right,  and  away  from  the  hemisphere  from  which  the  im- 
pulses originated.  But  this  lateral  deviation  or  conjugate 
deviation  of  the  eyes,  as  it  is  called,  occurs  frequently  in  disease, 
and  it  is  then  associated  with  rotation  of  the  head  and  neck  to 
the  same  side  as  the  eyes  are  directed.  This  position  of  the 
eyes  and  head  is  almost  a  constant  accompaniment  of  convul- 
sions of  cerebral  origin,  and  when  the  convulsions  are  unilateral 
and  due  to  disease  of  the  cortex  of  one  hemisphere,  the  rotation 
always  takes  place  towards  the  convulsed  side  and  away  from 
the  seat  of  the  lesion.  Unilateral  convulsions  are  often  asso- 
ciated with  a  certain  degree  of  hemiplegia,  the  convulsions  being 
then  limited  to  the  paralysed  side  ;  and  when,  under  these  cir- 
cumstances, conjugate  deviation  of  the  eyes  occurs,  the  rotation 
is  always  towards  the  paralysed  side.  This,  then,  constitutes 
spasmodic  lateral  deviation  of  the  head  and  eyes.  But  Graux^ 
has  drawn  attention  to  the  fact  that  this  lateral  deviation  is  often 
of  paralytic  origin.  Let  us  now  suppose  that  the  fibres  (2') 
which  connect  the  left  cortex  (C)  and  the  right  nucleus  of  the 
sixth  (er)  are  suddenly  interrupted,  the  cerebral  impulses  to  the 
nucleus  are  arrested,  the  external  rectus  of  the  right  eye  becomes 
paralysed,  and  that  eye  is  rotated  to  the  left.  But  the  impulses 
through  the  commissural  fibres  which  connect  the  nucleus  of  the 
right  sixth,  and  those  of  the  left  internal  rectus,  and  of  the 
rotators  of  the  head  to  the  left  must  also  be  arrested,  so  that  the 
latter  muscles  likewise  become  paralysed  ;  hence  the  left  eye  and 
the  head  become  rotated  to  the  left,  the  rotation  now  taking 
place  away  from  the  paralysed  side  and  towards  the  hemisphere 
of  th&  brain,  in  which  the  disease  is  situated.  The  rotation  of 
the  eyes  in  this  direction  has  been  facetiously  described  as  an 
attempt  on  the  part  of  the  patient  to  inspect  the  cerebral  lesion, 
which  is  the  cause  of  the  paralysis.     The  rotation  of  the  eyes, 

^  Graux  (G-aston).    De  la  paralysie  du  moteur  oculaire  exteme  avec  deviation 
conjugee.     Paris,  1878.    p.  132, 


INDIVIDUAL  MOTOR  MECHANISMS.  195 

head,  and  neck  is  not  now  due  to  spasm  of  the  muscles  engaged 
in  producing  the  action,  but  to  paralysis  of  their  antagonists. 
This  symptom  is  usually  associated  with  all  sudden  and  severe 
attacks  of  hemiplegia  ;  it  is  generally  absent  in  the  slighter 
forms  of  the  attack,  and  in  all  cases  in  which  the  paralysis  is 
more  or  less  gradual  in  its  onset.  The  phenomenon  is  alsoj  as  a 
rule,  a  very  transitory  symptom  in  hemiplegia,  and  usually  dis- 
appears in  from  four  days  to  a  week.  The  rotation  of  the  head 
generally  disappears  first,  and  then  the  deviation  of  the  eyes  im- 
proves; but  it  not  unfrequently  happens  that  a  temporary  squint 
may  be  observed  during  the  progress  of  the  rotation  of  the  eyes 
towards  recovery. 

The  reason  of  the  temporary  character  of  the  paralytic  form 
of  conjugate  deviation  of  the  eyes  and  rotation  of  the  head  and 
neck—say  towards  the  right — appears  to  be  that,  although  the 
nucleus  of  the  left  third  (r')  usually  receives  its  impulses  to 
action  through  the  commissural  fibres  which  connect  it  with  the 
nucleus  of  the  right  sixth  nerve  (er),  and  consequently  from  the 
cortex  of  the  left  hemisphere,  yet  channels  of  communication  (1) 
still  exist  between  the  nucleus  of  the  left  third  and  the  cortex  of 
the  right  hemisphere.  There  is  no  congenital  deficiency  of  the 
channels  which  connect  the  cortex  of  the  right  hemisphere  and 
the  nucleus  of  the  third  nerve  of  the  opposite  side,  nor  indeed 
of  the  oblique  commissural  fibres  which  connect  the  latter  with 
the  nucleus  of  the  right  sixth  nerve ;:  and  now  that  the  more 
usual  channels  are  interrupted  by  disease,  impulses  begin  to  pass 
through  the  less-used  channels.  In  a  few  days,  then,  the  channel 
(1)  between  the  right  cortex  and  the  nucleus  of  the  left  third 
nerve  becomes  patent,  and  some  days  later  the  commissural 
fibres  (c)  between  the  two  nuclei  become  so  far  open  as  to  convey 
impulses  from  the  nucleus  of  the  left  third  to  that  of  the  right 
sixth,  so  that  the  paralysis  of  the  muscles  supplied  by  these 
nerves  disappears.  A  destroying  lesion  in  the  pons  situated 
above  the  nucleus  of  origin  of  the  sixth  nerve,  but  below  the 
upper  crossing  of  the  fibres  of  the  pyramidal  tract,  causes  a 
conjugate  deviation,  which  is  directed  away  from  the  side  of  the 
lesion  and  towards  the  paralysed  limbs.  A  ease  is  reported  by 
Dr.  Hughlings  Jackson^  in  which  a  small  tumour  was  found  in 

'  Hughlings  Jackson.    Medical  Times  and  Gazette,  Lond.,  Vol.  I. ,  1874,  p.  9. 


196  ELEMENTARY  AFFECTIONS  OF 

the  floor  of  the  fourth  ventricle,  and  in  which  the  conjugate 
deviation  of  the  eyes  which  existed  during  life  was  directed  away 
from  the  side  of  the  lesion ;  many  more  or  less  similar  cases 
are  on  record.  It  has  also  been  shown  by  Graux^  that,  whereas 
disease  of  one  of  the  sixth  nerves  produces  an  internal  squint  of 
the  eye  on  the  side  of  the  lesion,  and  no  affection  of  the  other 
eye,  disease  of  the  nucleus  of  origin  of  one  of  the  sixth  nerves 
produces  a  conjugate  deviation  of  the  eyes,  the  external  rectus 
on  the  side  of  the  lesion  and  the  internal  on  the  opposite  side 
being  thus  more  or  less  paralysed.  But  the  internal  rectus  is 
not  completely  paralysed ;  although  it  does  not  act  when  the  eye 
has  to  be  directed  to  lateral  objects,  it  contracts  quite  well  in 
association  with  the  internal  rectus  of  the  opposite  eye  when  the 
eyes  are  converged  on  a  near  object  in  front.  These  facts  prove 
that  the  internal  rectus  muscle  is  innervated  by  fibres  issuing 
from,  or  at  least  passing  near  the  nucleus  of  origin  of  the  sixth 
nerve  of  the  opposite  side,  as  well  as  by  fibres  from  the  third 
nerve  of  the  same  side.  As  we  have  seen,  conjugate  deviation 
of  the  eyes  is  as  a  rule  a  transitory  symptom  in  hemiplegia,  but 
if  a  lesion  in  the  pons  interrupts  the  commissural  fibres  (c)  so 
as  to  prevent  impulses  passing  from  one  nucleus  to  another, 
a  second  lesion  situated  in  any  position  which  will  interrupt 
the  fibres  of  the  pyramidal  tract  will  then  produce  a  para- 
lytic conjugate  deviation  of  the  head  and  eyes  which  remains 
permanent.^ 

§  92.  Secondary  Deviation  of  the  Sound  Eye. — In  paralysis 
of  one  of  the  ocular  muscles,  say  of  the  external  rectus  of  the 
right  side,  the  eye  is  of  course  subject  to  internal  squint.  Now, 
if  during  recovery  from  this  condition,  when  the  conduction 
through  the  sixth  nerve  (Qn)  is  still  delayed,  the  eye  of  the 
sound  side  be  closed  and  the  patient  be  directed  to  look  at  an 
object  with  his  right  eye  in  such  a  way  as  to  strain  the  external 
rectus  muscle,  this  strain  is  accompanied  by  a  strong  voluntary 
effort;  but  owing  to  the  diminished  conductivity  of  the  nerve 
only  a  relatively  small  amount  of  the  voluntary  impulses  will 
pass  to  the  muscle.     But  the  impulses  generated  by  the  strong 

»  Graux.    Op.  Cit.,  p  65. 
^  Broadbent.    Medical  Times  and  Gazette,  Lond.,  Vol.  I.,  1872,  p.  554. 


INDIVIDUAL  MOTOR  MECHANISMS.  197 

voluntary  effort  will  pass  through  the  commissural  fibres  (c')  to 
the  nucleus  of  the  left  third  nerve  (/)  in  undiminished  degree, 
so  that  the  internal  rectus  of  the  left  eye  becomes  strongly 
contracted.  The  energetic  contraction  of  the  internal  rectus  of 
the  left  eye  induces  a  secondary  squint  in  it,  the  extent  of  which 
is  much  in  excess  of  that  of  the  squint  of  the  paralysed  side. 
But  although  this  secondary  deviation  is  more  apparent  in  the 
case  of  paralysis  of  the  ocular  than  in  paralysis  of  other  muscles, 
yet  essentially  the  same  phenomenon  occurs  in  the  extremities. 
If  the  common  extensor  muscle  of  the  toes  is  partially  paralysed 
a  voluntary  effort  to  extend  the  toes  is  followed  by  flexion  of  them, 
A  simple  movement  like  flexion  at  the  elbow  joint  is  not  caused 
by  contraction  of  the  flexors  only,  but  by  the  predominance  of 
their  contractions  over  the  contraction  of  the  extensors  simulta- 
neously induced.  During  recovery  from  an  attack  of  hemiplegia 
it  often  happens  that  when  the  patient  makes  an  effort  to  flex 
the  forearm  the  flexor  muscles  may  be  observed  to  contract,  yet 
either  no  movement  or  movement  in  the  opposite  direction 
occurs,  because  the  balance  of  the  innervation  to  the  antagonistic 
muscles  is  equal,  or  the  innervation  to  the  extensors  is  in  excess 
of  that  to  the  flexors. 

§  93.  Disorders  of  the  Associated  Movements  of  the  Extremi- 
ties.— We  have  seen  that  the  movements  of  the  limbs,  and 
especially  of  the  hand  of  one  side,  are  largely  independent  of 
those  of  the  other,  and  consequently  that  the  spinal  nuclei  of  the 
nerves  which  supply  the  limbs  are  not  intimately  connected  by 
transverse  commissural  fibres.  But  in  walking,  the  movement 
of  the  right  leg  is  always  associated  with  swinging  of  the  left 
arm,  and,  conversely,  that  of  the  left  leg  with  swinging  of  the 
right  arm.  It  may  be  inferred,  therefore,  that  the  nuclei  of  the 
nerves  of  the  upper  (a  a')  and  lower  extremities  {I  I')  are  con- 
nected by  oblique  and  crossed  commissural  fibres.  In  man  the 
movements  of  the  leg  of  one  side  are  not  very  intimately  asso- 
ciated with  that  of  the  arm  of  the  opposite  side;  hence  the 
commissural  fibres,  which  connect  their  respective  nerve  nuclei, 
are  represented  by  dotted  lines  {c^).  In  quadrupeds,  however, 
the  crossed  association  between  the  movements  of  the  anterior 
and  posterior  extremities  of  opposite  sides  is  much  more  intimate 


198  ELEMENTARY  AFFECTIONS  OF 

than  in  man,  and  consequently  the  oblique  commissural  fibres 
are  patent  in  a  corresponding  degree. 

Let  us  now  suppose  that  the  fibres  (4'  and  6'),  which  connect 
the  cortex  (C)  of  the  left  hemisphere  with  the  spinal  nuclei 
{a,  I)  of  the  right  extremities,  are  ruptured.  Rupture  of  these 
fibres  would  produce  hemiplegia  in  man  ;  but  in  the  dog  only  a 
certain  amount  of  paresis  results,  inasmuch  as  the  right  hind 
limb  receives  impulses  through  the  open  commissural  fibres, 
which  connect  the  spinal  nuclei  of  its  nerves  with  the  nuclei  of 
the  nerves  of  the  left  anterior  limb.  The  right  anterior  limb 
likewise  becomes  innervated  through  the  commissural  fibres, 
which  connect  the  nuclei  of  origin  of  its  nerves  with  those  of  the 
nerves  of  the  left  posterior  extremity.  All  the  limbs  of  the  dog 
therefore  become  innervated  from  one  hemisphere  when  the 
other  hemisphere  is  injured,  so  that,  although  disease  of  one 
hemisphere  causes  a  certain  amount  of  paresis,  no  true  paralysis 
or  hemiplegia  results  as  in  the  case  of  man.  This  condition  has 
often  been  induced  by  experimental  lesions  of  one  of  the  hemi- 
spheres in  the  dog,  and  it  is  always  associated  with  conjugate 
deviation  of  the  head  and  eyes,  showing  that  both  phenomena 
are  induced  by  disease  of  the  same  mechanism.  But  although 
the  dog  does  not  manifest  complete  paralysis  of  the  muscles  of 
the  side  opposite  the  lesion — say  the  right  side,  the  lesion  being 
in  the  left  hemisphere — yet,  on  standing,  a  slight  degree  of 
pressure  on  the  left  side  pushes  the  animal  over  to  the  right,  the 
vertebral  column  is  arched  with  the  convexity  towards  the  right, 
showing  a  predominance  of  the  action  of  the  left  erector-spin se 
over  their  antagonists,  and  the  eyes  and  head  are  rotated  to  the 
left,  a  position  which  indicates  paresis  of  the  muscles,  which 
produces  rotation  of  them  to  the  right.  Under  these  circum- 
stances, when  the  dog  endeavours  to  advance  he  begins  to  move 
round  his  tail,  a  movement  which  has  been  called  "  mouvement 
de  manage,"  and  which  is  the  equivalent  of  hemiplegia  in  man. 
It  is  therefore  probable  that  some  of  the  compulsory  movements 
described  as  Automatic  Kinesioneuroses  really  belong  to  the 
Synkineses,  as  at  present  defined. 

§  94,  Disorder  of  the  Associated  Movements  of  Articulation. 
But  when  the  muscles  which  are  bilaterally  associated  in  their 


INDIVIDUAL   MOTOR  MECHANISMS.  199 

action  are  small,  and  when  minor  nervous  discharges  only  are 
requisite  to  throw  them  into  action,  the  connection  of  the 
muscles  of  the  two  sides  with  one  hemisphere  may  be  brought 
into  such  habitual  use  that  the  connection  with  the  other  hemi- 
sphere, although  still  existing,  is  held  practically  in  abeyance. 
The  muscles  concerned  in  executing  the  movements  of  articula- 
tion, for  instance,  are  bilaterally  associated  ;  the  necessary  adjust- 
ments demand  great  delicacy  of  execution  but  no  great  muscular 
exertion ;  the  muscles  engaged  in  executing  the  most  delicate  of 
these  adjustments  are  small ;  and  consequently  these  muscles 
fulfil  all  the  conditions  just  mentioned. 

It  is  now  a  matter  almost  of  daily  observation  that  the 
muscular  adjustments  concerned  in  articulate  speech  are  regu- 
lated from  the  left  hemisphere;  but  it  by  no  means  follows 
that  the  regulation  of  all  the  functions  performed  by  these 
muscles  is  similarly  restricted.  The  contractions  of  the  laryn- 
geal muscles  concerned  in  vocalisation,  for  instance,  are  not 
necessarily  interfered  with,  because  the  delicate  adjustments 
required  in  articulate  speech  are  abolished  ;  hence  complete  loss 
of  the  power  of  articulate  speech  is  perfectly  compatible  with 
entire  absence  of  voluntary  paralysis  of  any  of  the  muscles 
engaged  in  articulation.  It  is  not  the  power  of  producing  volun- 
tary contractions  of  these  muscles  which  is  lost,  but  the  power 
of  producing  highly  complex  combinations  of  these  contractions. 
If  we  suppose  that  v  and  v  are  the  spinal  nuclei  of  the  nerves 
(v  n,  V  n'),  which  supply  the  muscles  of  articulation,  the  two 
nuclei  are  practically  fused  into  one  by  transverse  commissural 
fibres  (c") ;  and  consequently  impulses  which  start  from  the  left 
cortex  (C),  and  pass  through  the  fibres  (3')  to  the  spinal  nucleus 
{v)  of  the  right  side,  readily  reach  the  left  nucleus  {v')  through 
the  commissural  fibres  (c").  But  as  the  muscles  concerned 
in  articulation  act  always  bilaterally  and  symmetrically,  the 
channels  of  communication  between  the  spinal  nuclei  of  their 
nerves  and  the  cortex  of  one  hemisphere  are  brought  into 
habitual  use ;  while  the  channels  of  communication  between 
these  nuclei  and  the  opposite  hemisphere  become  partially 
obliterated  from  disuse,  and  probably  not  thoroughly  developed 
from  the  first.  The  channels  of  communication  between  the 
right  cortex  (C)  and  the  nuclei  v  and  v\  for  instance,  are  repre- 


200  ELEMENTARY  AFFECTIONS   OF 

sented  by  the  dotted  line  (3  3),  and  tbe  commissural  fibres 
which  convey  impulses  from  the  left  to  the  right  nucleus  by  the^ 
dotted  line  (c"),  in  order  to  indicate  that  these  channels  are  only 
partially  open.  Destruction  of  the  communication  (3')  between 
the  left  cortex  (C)  and  the  right  nucleus  (v)  is  followed  by  loss 
of  articulate  speech,  a  condition  which  is  called  aphasia. 

If  the  lesion  destroy  the  portion  of  the  cortex  of  the  left 
hemisphere — the  posterior  part  of  the  third  frontal  convolution — 
from  which  the  fibres  of  communication  spring,  this  condition 
is  permanent,  except  perhaps  in  young  people,  in  whom  the 
corresponding  part  of  the  right  hemisphere  becomes  educated 
and  developed  for  the  purpose.  But  if  the  lesion  involve  only 
the  channel  of  communication  (3')  between  the  left  cortex  and 
the  right  nucleus,  the  loss  of  speech  is  only  temporary.  The 
corpus  callosum  consists  of  fibres  (c  c),  which  connect  sym- 
metrical parts  of  the  two  hemispheres ;  and  the  portion  of  it 
which  connects  the  third  frontal  convolution  of  the  two  sides  is 
represented  in  Fig.  14  by  the  dotted  line,  to  show  that  although 
the  connection  exists  it  is  partially  closed  through  disuse. 
When,  however,  the  communication  through  (3')  is  interrupted, 
impulses  generated  in  the  third  left  frontal  convolution  make 
their  way  through  tbe  fibres  of  the  corpus  callosum  to  the  cor- 
responding part  of  the  right  hemisphere,  and  after  a  time 
through  the  dotted  line  (3),  which  connects  the  latter  with  the 
left  nucleus,  and,  after  another  interval,  through  the  partially 
open  commissural  fibres  which  connect  the  left  (y)  with  the 
right  nucleus  {v),  so  that  the  power  of  speech  is  gradually 
re-acquired.  A  lesion,  however,  which  destroys  both  the  channel 
of  communication  (3')  between  the  third  left  frontal  convolution 
and  the  spinal  nuclei,  and  the  fibres  of  the  corpus  callosum 
(c  G  dotted  line),  connecting  the  right  and  left  third  frontal  con- 
volutions, will  influence  speech  as  powerfully  and  permanently 
as  disease  of  the  grey  substance  of  the  third  left  frontal  con- 
volution itself.  Such  a  lesion  effectually  cuts  off  the  third  left 
frontal  convolution,  in  which  the  higher  mechanism  which 
regulates  the  muscular  adjustments  concerned  in  articulation  is 
organised,  from  the  spinal  nuclei;  and  the  only  means  by 
which  speech  can  be  then  restored  is  the  organisation  of  a  new 
mechanism  in  the  corresponding  part  of  the  right  hemisphere,  a 


INDIVIDUAL   MOTOR  MECHANISMS.  201 

method  which  must  always  be  slow,  and  which  can  only  take 
place,  at  least  to  any  considerable  extent,  in  the  plastic  tissues 
of  young  people. 

For  this  exposition  of  the  phenomena,  which  I  have  grouped 
together  under  the  term  Synkineses,  I  am  myself  responsible ; 
but  the  whole  of  what  I  have  said  is  inspired  by  the  succession 
of  able  contributions  on  the  subject  from  the  pen  of  Dr. 
Broadbent.  To  Dr.  Broadbent,  indeed,  we  owe  the  enunciation 
of  the  principle  of  the  bilateral  association  of  the  nerve  nuclei 
of  the  muscles  bilaterally  associated  in  their  action,  which 
affords  the  key  to  the  interpretation  of  the  phenomena,  and  the 
subject  has  been  worked  out  by  him  with  such  fulness  of  detail 
and  such  consummate  skill  that  little  is  left  to  others  in  this 
field  but  to  copy  his  work. 

(II.) -MOTOR  AFFECTIONS  OF  INTERNAL  ORGANS  (VISCERAL 
KINESIONEUROSES). 

§  95.  The  motor  affections  of  internal  organs,  exclusive  of 
the  disturbances  of  the  blood-vessels,  present  many  peculiarities 
in  comparison  with  those  of  the  organs  of  external  relation. 
These  peculiarities  depend  in  great  part  upon  the  fact  that  the 
muscular  apparatus  of  the  internal  organs  is  formed  of  unstriated 
muscular  tissue,  which  differs  from  the  striated  muscle  in  its 
mode  of  contraction,  and  in  several  other  respects.  An  unstriated 
muscular  fibre  does  not  respond  to  mechanical  and  electrical 
stimuli  by  a  prompt  contraction  of  short  duration ;  but  the  con- 
traction is  preceded  by  a  long  latent  period  and  lasts  a  consider- 
able time,  after  which  relaxation  slowly  takes  place.  The  slow 
and  protracted  nature  of  the  contraction  of  unstriated  muscular 
fibres  renders  it  impossible  for  tremor  and  fibrillary  contractions 
to  appear  as  symptoms  in  affections  of  those  muscles. 

Another  important  peculiarity  of  the  contractions  of  unstriated 
muscles  is  their  rhythmic  and  automatic  character.  The  peri- 
stalsis of  the  intestines  and  ureters  is  rhythmic,  and  probably  in 
great  part  automatic.  It  is  very  probable  that  these  movements 
depend  in  great  measure  upon  the  presence  of  local  ganglia  in 
the  walls  of  the  organs,  and  such  ganglia  have  been  anatomically 
demonstrated  in  the  heart,  stomach,  intestines,  uterus,  and  other 
organs.       Co-ordinating    arrangements    appear   to    be    present 


202  ELEMENTARY  AFFECTIONS   OF 

between  these  ganglia,  which  regulate  the  contractions  of  the 
various  segments  of  the  viscus,  so  that  they  contract  in  orderly 
sequence. 

The  functions  of  these  intramural  ganglia  are  regulated  by 
means  of  accelerating  and  retarding  nerve  fibres  from  the 
cerebro-spinal  system.  Inhibitory  nerve  fibres  pass  to  the  heart 
along  the  vagus,  and  to  the  intestines  in  the  splanchnic  nerves  ; 
while  the  accelerating  fibres  to  the  heart  pass  along  the  lowest 
cervical  and  uppermost  thoracic  ganglia  of  the  sympathetic,  and 
to  the  intestines  from  the  sympathetic  plexuses  of  the  abdomen. 

It  must  also  be  noticed  that  acceleration  or  inhibition  of  the 
visceral  movements  may  be  produced  by  irritation  of  certain 
centres  in  the  cord  and  brain.  Centres  for  the  movements  of 
the  bladder  and  rectum,  and  for  erection  and  ejaculation,  are 
found  in  the  lumbar  portion  of  the  cord,  and  for  the  movements 
of  the  blood-vessels  in  the  entire  length  of  the  cord  and  in  the 
medulla  oblongata.  The  activity  of  these  centres  is  evoked  by 
means  of  peripheral  irritation,  and  consequently  their  functions 
may  be  regarded  as  being  in  great  part  of  reflex  nature.  These 
centres  of  innervation  are  also  connected  by  means  of  exciting 
and  inhibitory  fibres  with  the  cortex  of  the  cerebrum,  so  that  the 
functions  of  the  bladder,  rectum,  and  other  organs  are  brought 
to  some  extent  under  voluntary  control 

From  what  has  just  been  said,  it  is  manifest  that  the  concep- 
tions of  spasm  and  paralysis,  which  are  applicable  to  the  conditions 
of  excess  or  diminution  of  the  activity  of  the  striated  muscles,  are 
not  applicable  to  the  corresponding  conditions  of  the  unstriated 
muscles.  In  the  normal  condition  the  muscular  fibres  of  the 
internal  organs  are  maintained  in  a  state  of  rhythmic  contraction. 
A  due  degree  of  this  contracted  condition  may  be  regarded  as 
the  normal  tonus  of  the  organ.  The  condition  of  motor  excess, 
or  of  increased  tonus,  may  be  called  hypertony;  while  that  of 
muscular  weakness  or  relaxation  constitutes  Atony  (Eulenburg). 
This  change  in  the  tonicity  may  be  of  direct  or  of  reflex  origin. 

But  pathological  anomalies  in  the.territory  of  the  inhibitory 
fibres  or  of  the  inhibitory  centres  may  lead  to  corresponding 
motor  disturbances  of  the  viscera.  Irritation  of  the  inhibitory 
fibres  and  centres  will  give  rise  to  paresis  or  complete  paralysis 
of  the  corresponding  muscles,  while  inactivity  of  these  fibres  and 


INDIVIDUAL  MOTOR  MECHANISMS.  203 

centres  will  give  rise  to  spasm  or  tetanus  of  the  muscles.  Dis- 
turbances of  motor  co-ordination  of  the  visceral  muscles,  as,  for 
instance,  of  erection,  ejaculation,  and  the  mechanism  of  urination 
and  defaecation,  may  occur,  analogous  to  the  inco-ordination  of 
the  movements  of  the  muscles  of  external  relation  observed  in 
locomotor  ataxy  and  other  diseases. 

From  what  has  been  said  it  is  evident  that  the  visceral  motor 
disturbances  must  be  more  complicated  than  those  of  the  volun- 
tary muscles ;  and  it  will  be  useful,  before  proceeding  further,  to 
illustrate  the  nervous  mechanism  which  regulates  the  movements 
of  the  internal  organs  by  giving  a  somewhat  detailed  analysis  of 
the  innervation  of  the  most  important  of  them.  The  mechanisms 
which  regulate  the  movements  of  the  heart,  and  of  the  respiratory 
and  genito-urinary  organs,  are  better  known  than  those  of  other 
internal  organs;  and  they  will,  therefore,  best  serve  to  illustrate 
the  general  arrangements  of  visceral  innervation. 

§  96.  Innervation  of  the  Heart. 

The  nervous  centres  which  preside  over  the  movements  of  the  heart 
consist  of  the  intracardiac  gangha,  centres  in  the  medulla  oblongata,  and 
centres  in  the  cortex  of  the  brain.  The  position  of  these  centres  may  be 
illustrated  by  the  annexed  diagram  {Fig.  15).  The  cardiac  muscle  is  repre- 
sented by  H,  and  the  endocardium  by  E  ;  CA  represents  the  intramural 
cardiac  motor  ganglia,  MA  and  MI  the  motor  accelerating  and  the  motor 
inhibitory  centres  in  the  medulla  oblongata  respectively,  and  B  the  cortical 
centre  in  the  brain.  These  centres  are  connected  with  the  periphery,  and 
with  one  another  in  various  ways.  First,  afferent  fibres  {a)  connect  the 
endocardiimi  with  the  intramural  motor  ganglia  (CA),  and  from  the  latter 
issue  fibres  (e)  which  are  distributed  to  the  cardiac  muscle  (H).  This 
constitutes  a  simple  reflex  mechanism.  Second,  intercentral  fibres  (e') 
which  connect  the  motor  accelerating  centre  (MA)  in  the  medulla  and  the 
intramural  cardiac  ganglia  (CA) ;  they  convey  impulses  which  increase 
the  activity  of  the  heart,  and  are  consequently  called  accelerating  fibres. 
Third,  intercentral  fibres  {e"  and  e"')  between  the  centre  (MI)  in  the 
medulla  and  the  intramm-al  motor  ganglion  (CA) ;  they  carry  impulses  which 
arrest  the  action  of  the  heart,  and  are  therefore  called  cardio-inhihitory 
fibres.  Various  physiological  facts,  to  be  immediately  mentioned,  seem  to 
indicate  that  between  the  cardio-inhibitory  centre  in  the  medulla  (MI)  and 
the  intramural  motor  ganglia  (CA)  intermediate  ganglia  (CI)  are  interposed, 
which  from  their  action  are  called  intramural  cardio-inhibitory  ganglia. 
Fom-th,  afferent  fibres  {a'),  connecting  some  portion  of  the  periphery  and 
the  motor  centre  in  the  medi^a,  and  stimulation  of  which  excites  the  centre 


204 


ELEMENTARY  AFFECTIONS  OF 


Fig.  15. 


to  increased  action.  These  fibres  are,  from  their  action,  called  excito-motor, 
although  affero-accelerating  fibres  would  best  characterise  their  function. 
Fifth,  afferent  fibres  {a"),  which  connect  some  portion  of  the  periphery  with 
the  cardio-inhibitory  centre  in  the  medulla,  and  irritation  of  which  renders 

the  action  of  the  heart  slower.  These 
fibres  are  called  excito-inMbitory  ;  but 
afero-inhihitory  would  best  charac- 
terise their  functions.  Sixth,  afferent 
fibres  {a'"),  which  connect  the  surface 
of  the  body  either  directly  or  indirectly 
with  the  cortical  centre  (B).  Seventh 
and  eighth,  fibres  (c  and  </)  which 
connect  the  cortex  of  the  opposite 
hemisphere  of  the  brain  with  the 
cardio- motor  and  cardio-inhibitory 
centres  in  the  medulla.  These  fibres 
may  respectively  be  called  centrifugo- 
motor  and  centrifugo-inhihitory.  It 
will  be  seen,  therefore,  how  exceed- 
ingly compUcated  the  cardiac  nervous 
mechanism  is,  and  in  what  a  variety 
of  ways  it  may  be  deranged. 

1.  Disturbances  of  the  Simple  Reflex 
Cardiac  Mechanism. — The  heart  may 
be  thrown  into  action,  as  Bernard  has 
proved,  by  stimulating  the  endocar- 
dium, a  fact  which  shows  that  afferent 
fibres  terminate  in  this  membrane, 
which  connect  it  with  the  intramural 
gangUa,  and  through  efferent  fibres 
with  the  muscle  of  the  heart.  Poisons 
which  act  on  the  muscular  substance 
of  the  heart,  as  the  salts  of  potassium, 
lactic  acid  and  its  salts,  and  various 
other  agents,  of  course  destroy  this 
mechanism,  but  only  in  an  indirect 
manner,  by  rendering  the  muscle 
incapable  of  responding  to  a  nervous 
stimulus.  Such  poisons  arrest  the 
action  of  the  heart  in  diastole. 

2.  Disturbances  of  the  Cardio-in- 
hibitory Mechanism : — 

(a)  Affections  of  the  Inhibitory 
Fibres  of  the  Vagus. — The  beat  of 
the  heart  may  be  checked  or  entirely 
stopped  yin  diastole  by  efferent  im- 


■  /  B     ) 

'    ■  1 

e  :  ' 

Inn 

r'-'- 

;   I    1  (ci) 

1,1 

III 

\     ,'  •  i            B 

1  ,  1,      . 

MeBB 

.1^    1    -1        '      ' 

|g| 

Tig.  15.  Schema  of  the  Action  of  the 
Cardiac  Nervous  Mechanism. — CA, 
intramural  motor  ganglia  of  the 
heart;  CI,  intramural  inhibitory 
ganglia ;  MI  and  MA,  centres  in  the 
medulla  oblongata,  the  former  being 
inhibitory,  the  latter  motor;  B, 
centre  in  cortex  of  brain ;  a,  afferent 
fibre  to  intramural  ganglion  cell ;  a', 
afiferent-motor  or  excito-motor  fibre ; 
a",  afferent  inhibitory  or  excito-inhi- 
bitory  fibre ;  a"',  afferent  fibres  con- 
necting periphery  with  cortex  of 
brain;  ef,  effero-motor fibre;  e" and  e"', 
effero-inhibitory  fibres ;  e,  e,  efferent 
fibres  of  the  reflex  arc  of  the  motor 
intramural  ganglia ;  c,  c',  fibres  con- 
necting the  cortex  of  the  cerebrum 
with  the  centres  in  the  medulla 
oblongata.  The  arrows  indicate  the 
direction  of  the  conduction. 


INDIVIDUAL   MOTOR  MECHANISMS.  205 

pulses  through  the  vagus  nerve.  The  stimulus  usually  employed  to  generate 
these  impulses  is  the  interrupted  ciu-rent ;  but  the  same  effect  is  produced, 
though  less  readily,  by  mechanical  and  chemical  stimuli.  Czermak,  by 
pressing  his  vagus  against  a  small  osseous  tumour  in  his  neck,  was  able  to 
arrest  temporarily  the  beating  of  his  own  heart. 

The  inhibitory  fibres  of  the  vagus  (e")  are  paralysed  by  curara,  so  that 
after  its  use  the  action  of  the  heart  becomes  accelerated,  and  stimulation 
of  the  vagus  produces  no  cardio-inhibitory  action.  Electrical  stimulation 
about  the  sinus-venosus  still,  however,  inhibits  the  cardiac  beats,  and  to 
account  for  this  the  presence  of  intramural  cardio-inhibitory  ganglia  are 
assumed.  The  influence  of  this  local  inhibitory  mechanism  is  well  illustrated 
by  the  action  of  several  other  drugs  upon  the  heart.  As  we  have  seen  curara 
paralyses  the  terminal  fibres  of  the  vagus,  while  the  initial  effect  of  nicotine 
is  to  stimulate  them,  but  neither  affects  the  intramural  inhibitory  ganglia, 
therefore  the  actions  of  curara  and  nicotine  are  strictly  antagonistic. 
Atropia,  again,  paralyses  the  intramural  inhibitory  mechanism,  while 
physostigmia  stimulates  it,  and  consequently  these  drugs  are  strictly 
antagonistic  in  their  actions.  But  although  atropia  and  nicotine,  and 
curara  and  physostigmia  have  opposite  effects  on  the  cardiac  rhythm,  yet 
they  are  not  mutually  antagonistic.  Thus  atropia  will  check  the  action 
of  nicotine,  but  ;nicotine  does  not  affect  the  operation  of  atropia,  and  a 
similar  remark  applies  to  the  respective  actions  of  curara  and  physostigmia. 
Muscarin  and  jaborandi  produce  standstill  of  the  heart  which  may  be 
removed  by  atropia,  yet  neither  of  the  former  drugs  has  any  influence 
upon  the  action  of  the  latter.  From  this  it  is  inferred  that  muscarin  and 
jaborandi  stimulate  the  inhibitory  fibres  of  the  vagus,  but  do  not  affect  the 
intramural  cardio-inhibitory  mechanism. 

(6)  Affections  of  the  Inhibitory  Centre  in  the  Medulla. — In  acute  and 
chronic  diseases  of  the  base  of  the  brain  the  rhythm  of  the  heart  is  often 
greatly  changed,  and  this  is  probably  due  to  irritation  or  paralysis  of  the 
cardio-inhibitory  centre  in  the  medulla.  In  tubercular  meningitis,  for 
instance,  the  pulse,  which  is  at  first  very  slow,  becomes  exceedingly  quick 
towards  the  terminal  period  of  the  disease,  phenomena  which  are  best 
explained  by  supposing  a  primary  irritation  and  secondary  paralysis  of  the 
cardio-inhibitory  centre  in  the  medulla.  Direct  stimulation  of  the  centre 
in  the  medulla  oblongata  produces  inhibition  of  the  heart. 

(c)  Affections  of  the  Reflex  Inhibitory  Mechanism. — It  would  appear  that 
powerful  stimulation  of  any  part  of  the  body  wiU  produce  reflex  inhibition 
of  the  heart.  Crushing  of  a  frog's  foot  will,  for  instance,  stop  the  cardiac 
beats;  and  in  man,  fainting  from  severe  pain  appears  to  be  caused 
by  an  inhibitory  action  on  the  heart.  But  it  is  probable  that  in  the  latter 
instance  the  afferent  impulses  are  first  conveyed  to  the  cortex  of  the  brain 
and  are  thence  reflected  to  the  inhibitory  centre  in  the  medulla,  so  that  it 
can  scarcely  be  called  a  true  reflex  action.  Injury  of  the  intestines,  however, 
appears  to  exercise  a  more  powerful  effect  than  that  of  any  other  part  of 
the  body  on  the  action  of  the  heart.    If  the  abdomen  of  a  frog  be  laid  bare 


206  ELEMENTARY  AFFECTIONS   OF 

and  the  intestines  be  sharply  struck,  the  heart  will  stand  still  in  diastole 
just  as  occurs  in  powerful  stimulation  of  the  vagus;  cardiac  inhibition 
is  also  produced  if  the  mesenteric  nerves  or  their  connection  with  the 
sympathetic  system  be  stimulated  with  the  interrupted  current.  When, 
however,  both  vagi  are  divided,  or  the  mediolla  oblongata  is  destroyed 
prior  to  the  stimulation  of  the  intestines  or  mesenteric  nerves,  the  cardio- 
inhibitory  action  fails  to  be  produced. 

3.  Disturbances  of  the  Accelerator  Nerves. — After  division  of  the  vagus 
the  heart's  beat  may  be  quickened  by  direct  stimulation  of  the  spinal  cord. 
Certain  fibres  pass  from  the  cervical  spinal  cord  along  the  nerve  accom- 
panying the  vertebral  artery,  and  reach  the  heart  through  the  last  cervical 
and  first  thoracic  ganglia,  and  stimulation  of  these  by  means  of  the  inter- 
rupted current  causes  a  quickening  of  the  heart's  beat ;  hence  they  have 
been  called  the  accelerator  nerves  of  the  heart.  But  although  irritation 
of  these  nerves  causes  a  quickening  of  the  activity  of  the  heart,  yet 
abolition  of  their  conduction  does  not  render  the  action  of  the  heart 
slower,  because  they  are  not,  like  the  vagus,  constantly  in  action,  and 
therefore,  after  division  of  them,  the  activity  of  the  intracardiac  ganglia 
remains  unaffected.  These  accelerating  and  inhibitory  nerves  are  not  to 
be  regarded  as  antagonistic,  inasmuch  as  they  do  not  neutralise  one  another 
on  simultaneous  stimulation ;  each  produces  its  characteristic  effect,  whether 
the  other  be  stimulated  or  not.  They  are  perhaps  connected  with  the  in- 
tramural cardiac  nerves  in  differemi  ways ;  the  vagus,  probably,  being  asso- 
ciated with  the  intramural  inhibitory  ganglia,  and  the  accelerator  nerves 
directly  with  the  intramural  motor  ganglia. 

4.  Disorders  of  the  Rhythm  of  the  Heart. — It  is  evident  that  a  very  slight 
derangement  of  the  exquisitely  dehcate  and  complex  nervous  mechanism 
by  which  the  activity  of  the  heart  is  regulated  must  suffice  to  produce 
grave  disorder  in  the  regularity  of  its  rhythmic  contractions.  Irregularity 
in  the  pulsations  of  the  heart  and  other  rhythmic  anomalies  are  grouped 
under  the  term  arythmia  cordis;  and  this  condition  may  be  caused  by 
a  sUght  loss  of  balance  between  the  irritability  of  the  various  centres 
and  conducting  paths  of  which  the  nervous  mechanism  of  the  heart 
consists. 

§  97.  Innervation  of  the  Respiratory  Mechanism. 

The  nerve  centres  which  preside  over  the  movements  of  the  respiratory 
mechanism  are  situated  in  the  spinal  cord,  medulla  oblongata,  and  cortex 
of  the  brain.  The  spinal  centres  consist  of  the  nuclei  of  origin  of  the  ex- 
ternal thoracic,  phrenic,  and  spinal  accessory  nerves,  and  to  these  may  be 
added  the  nuclei  of  origin  of  the  nasal  branches  of  the  facial  nerve,  and 
]probably  also  the  nuclei  of  origin  of  some  of  the  fibres  of  the  superior 
laryngeal  nerve,  even  although  the  latter  nuclei  are  situated  in  the  medulla 
oblongata.  These  nuclei  are  superimposed  upon  one  another  and  form  a 
continuous  column  of  grey  matter  extending  from  the  lower  end  of  the 


INDIVIDUAL  MOTOR  MECHANISMS.  207 

dorsal  region  of  the  spinal  cord  upwards  to  a  point  opposite  the  calamus 
scriptorius  of  the  fourth  ventricle. 

The  respiratory  centres  in  the  medidla  are  situated  beneath  the  floor  of 
the  fourth  ventricle,  at  the  nuclei  of  origin  of  the  pneumogastric  and  spinal 
accessory  nerves.  Destruction  of  this  centre  arrests  all  respiratory  move- 
ments, and  consequently  Flourens  called  it  the  Noeud  Vital,  or  Vital  Knot. 
It  has,  indeed,  been  found  by  Langendorff^  that  in  newly-born  animals 
after  the  excitability  of  the  spinal  cord  has  been  increased  by  the  admini- 
stration of  strychnia,  spontaneous  respiratory  movements  continue  for  a 
quarter  of  an  hour  after  decapitation  or  section  of  the  cord  below  the 
medulla,  and  he  infers  that  the  spinal  cord  contains  centres  of  respiration 
which  act  both  reflexly  and  automatically.  A  second  respiratory  centre  has 
been  discovered  by  Drs.  Martin^  and  Booker,  and  later  by  Christiani,^ 
situated  beneath  the  posterior  corpora  quadrigemina  and  close  to  the  iter, 
and  irritation  of  which  causes  "accelerated  inspirations,  finally  passing  into 
tetanic  fixation  of  the  chest  in  an  inspiratory  condition." 

The  positions  occupied  by  the  cortical  motor  centres  are  not  well 
ascertained,  but  they  are  doubtless  situated  in  the  motor  area. 

The  reflex,  automatic,  and  psychical  respiratory  centres  are  connected 
with  one  another  and  with  the  periphery  in  various  ways. 

The  cortical  centres  are  doubtless  connected  with  the  automatic  centres 
in  the  medulla  and  probably  also  directly  with  the  reflex  centres  in  the 
spinal  cord  by  centrifugal  fibres  which  run  in  the  pyramidal  tract,  but  the 
com-se  of  which  is  not  yet  well  ascertained. 

There  is  a  respiratory  centre  in  each  lateral  half  of  the  medulla,  and 
these  are  connected  with  each  other  by  crossed  commissural  fibres.  From 
his  experiments  LangendorfF  is  led  to  believe  that  a  nerve  bundle  issues 
from  the  nuclei  of  the  vagus  and  trigeminus  of  one  side  which  passes  down- 
wards to  be  connected  partly  with  the  phrenic  of  the  same  side  and  partly 
with  that  of  the  opposite  side,  so  that  a  decussation  occurs  somewhat 
resembhng  that  in  the  optic  chiasma.  Median  section  of  the  medulla 
severs  the  decussating  fibres,  and  after  the  operation  any  disturbance  of 
the  vagus  or  trigeminus  of  one  side  causes  disturbances  on  that  side  only, 
instead  of  both  sides  being  affected  as  they  would  have  been  prior  to  the 
section.  The  respiratory  centres  in  the  medulla  are  connected  with  the 
spinal  centres  probably  by  cells  as  well  as  by  fibres.  The  respiratory  centre  in 
the  medulla  must  not  be  supposed  to  be  a  localised  mass  of  grey  matter 
distinctly  separated  from  the  spinal  nuclei.  It  appears  only  to  be  the 
upper  expanded  termination  of  the  column  of  grey  matter  already  described 
as  representing  the  spinal  nuclei.  The  respiratory  centres  in  the  medulla 
are  connected  with  the  periphery  chiefly  by  means  of  the  vagi,  while  the 
spinal  nuclei  are  connected  with  it  by  means  of  the  thoracic,  the  spinal 

'  Langendorfif .    Du  Bois-Reymond's  Archiv. ,  1880,  p.  51 8. 

'  Martin  and  Booker.     The  influence  of  stimulation  of  the  mid-brain  upon  the 
respiratory  rhythm  of  the  mammal.     Journal  of  Physiology,  Vol.  I.,  1879,  p.  370. 
^  Christiani.     Centralbl.  f.  d.  med.  Wissensch.,  1880,  p.  273. 


208  ELEMENTARY  AFFECTIONS   OF 

accessory,  the  nasal  branches  of  the  facial,  and  the  trigeminal  nerves. 
The  cortical  respiratory  centres  are  connected  with  the  periphery  either 
directly  or  indirectly  through  all  the  afferent  nerves  of  the  body,  and  conse- 
quently any  impression  made  upon  the  surface  of  the  body  may  interfere 
with  the  respiratory  rhythm. 

The  rhythmical  action  of  the  respiratory  centre,  although  variously 
modified  by  afferent  impulses  conveyed  to  it,  yet  is  probably  due  to  auto- 
matic and  not  to  reflex  action.  The  exciting  cause  of  the  respiratory 
movements  is  the  presence  of  a  certain  amoimt  of  oxygen  and  carbonic 
acid  in  the  blood,  respiration  becoming  stronger  the  less  the  quantity  of 
oxygen  and  the  more  of  carbonic  acid  it  holds. 

The  rhythmical  movements  of  respiration  are  variously  modified  by 
irritation  of  afferent  fibres.  Breathing  is  arrested  in  inspiration  for  a 
short  time  by  cold  suddenly  appUed  to  the  surface  of  the  body,  the  im- 
pulses being  conveyed  to  the  centre  by  the  cutaneous  nerves.  It  is  tem- 
porarily arrested  in  expiration  by  a  sudden  irritation  of  the  mucous 
membrane  of  the  nose,  the  ii-ritation  being  now  conveyed  through  the 
branches  of  the  fifth  nerve.  But  the  most  important  afferent  impulses 
which  affect  the  automatic  action  of  the  centre  are  those  conducted  by  the 
vagi.  If  one  vagus  be  divided,  the  breathing  becomes  slower  ;  and  if  both 
be  divided,  respiration  becomes  excessively  slow,  but  much  fuller  and 
deeper  than  normal,  so  that  what  is  lost  in  rate  is  gained  in  extent,  and 
thus  the  gaseous  exchange  is  not  sensibly  interfered  with.  Both  the 
superior  and  the  inferior  laryngeal  nerves  contain  fibres  which,  on  being 
stimulated  by  a  powerful  faradic  current,  produce  respiratory  arrest  in 
expiration.  Dr.  J.  Campbell  Graham  ^  has  found  that  faradisation  of  the 
splanchnic  nerve  in  rabbits  below  the  diaphragm  produces  relaxation  of  the 
diaphragm,  and  contraction  of  the  abdominal  muscles,  so  that  it  would 
appear  that  these  nerves  also  contain  affero-inhibitory  fibres.  When  the 
central  end  of  one  of  the  divided  vagi  is  stimulated,  the  respiration  which 
had  become  slower  after  division  of  the  nerve  is  quickened  again  ;  and  if  a 
strong  stimulus  be  employed,  the  diaphragm  undergoes  a  tetanic  contraction, 
and  respiration  is  arrested  in  the  position  of  deep  inspiration.  But  if  the 
central  end  of  the  superior  laryngeal  nerve  be  stimidated,  the  breathing 
becomes  slower,  and  strong  stimidation  of  the  nerve  may  arrest  respiration 
in  the  position  of  deep  expiration.  These  experiments  prove  that  the 
vagus  contains  afferent  regulator-nerves,  the  main  tnmk  containing  affero- 
aceeleraiing,  and  the  superior  laryngeal  branch  affero-inhihitory  fibi'es. 
Diflferent  opinions  have  been  held  with  regard  to  the  manner  in  which 
the  acceleratory  and  inhibitory  fibres  of  the  vagus  act  in  regidating  the 
respiratory  rhythm.  The  affero-accelerating  fibres  appear  to  be  in  constant 
action ;  and  EosenthaP  thinks  that  the  impidses  conveyed  through  them  to 

'  Graham  (J.  P.).  "  Ein  naues  specifisches  regulatorisches  Nervensystem  des 
athemcentrums."    Pfluger's  Archiv.,  XXV.,  1880,  p.  379. 

*  Rosenthal.  "Neiie  Studien  iiber  Athembewegungen."  Du  Bois-Reymond'a 
Archiv.  f.  Physiol.  Suppl.  Bd.,  1880,  p.  34;  and  1881,  p.  39. 


INDIVIDUAL  MOTOR  MECHANISMS.  209 

the  respiratory  centre  in  the  medulla  diminishes  the  specific  resistance  of 
that  centre,  and  thus  increases  the  number  of  individual  impulses  sent 
outwards  to  the  respiratory  muscles  in  a  given  time.  Division  of  the  vagi 
increases  the  specific  resistance  of  the  centre,  and  consequently  the  nimaber 
of  centrifugal  impulses  generated  in  a  given  time  are  diminished,  but  the 
strength  of  each  impulse  is  increased  in  a  corresponding  degree.  The 
afferent  impulses  ascending  along  the  superior  laryngeal  nerve  may  be 
regarded  as  increasing  the  central  resistance,  and  thus  slowing  the 
respiratory  rhythm.  According  to  this  view,  stimulation  of  the  vagus  does 
not  increase  the  activity  of  the  respiratory  centre,  but  only  distributes  the 
energy  in  a  different  manner.  But  this  opinion  is  by  no  means  accepted 
without  question  by  other  physiologists.^  Breuer^  and  Hering^  think  that 
distension  of  the  limgs  acts  as  an  excitant  to  the  inhibitory  fibres,  and 
thus  induces  an  expiratory  act ;  while  contraction  of  the  limg  excites  the 
accelerating  fibres,  which  then  initiate  an  inspiration.  The  experiments  of 
Langendorff*  appear  to  confirm  this  theory.  He  found  that  artificial 
inflation  of  the  lungs  produces  an  expiration  m  non-narcotised  animals, 
which  failed  to  take  place  when  the  vagi  were  divided,  thus  showing  that 
the  resulting  contraction  of  the  chest  is  due  to  the  influence  which  dis- 
tension of  the  lungs  exerts  upon  the  nervous  mechanism.  It  is  very 
probable  that  we  must  assume  the  existence  of  an  inspiratory  and  an 
expiratory  centre  in  the  medulla,  but  the  whole  of  the  subject  is  beset  with 
difficulties  which  cannot  be  satisfactorily  met  in  the  present  state  of  our 
knowledge. 

Disorders  of  the  Nervous  Mechanism  of  Respiration. 

(1)  Accelerated  Breathing. — When  the  blood  is  deficient  in  oxygen  and 
charged  with  carbonic  acid  the  respiratory  centre  in  the  medulla  is 
stimulated  and  the  respiratoy  rhythm  is  accelerated. 

(2)  Dyspnoea. — When  respiration  is  accompanied  by  a  distressing  con- 
sciousness of  want  of  breath,  arising  either  from  undue  irritability  of  the 
nervous  mechanism,  as  in  hysteria,  or  from  insufficient  aeration  of  the 
blood,  as  in  organic  diseases  of  the  lungs  and  heart,  the  accessory  muscles 
of  respiration  are  thrown  into  action,  and  the  condition  is  called  dyspnoea. 
We  have  seen  the  effect  which  distension  of  the  lungs  has  in  provoking 
expiration  and  conversely  of  contraction  of  the  lung  in  exciting  inspiration ; 
when  there  is  an  obstruction  to  the  passage  of  air  to  and  from  the  lungs 
the  limits  of  distension  and  contraction  are  reached  slowly  and  with 
difl&culty,  and  consequently  the  dyspnoea  is  declared  not  so  much  by  the 

*  See  Gad  (J.).  "Die  Regulirung  der  normalem  Athmung."  Du  Bois-Rey- 
mond's  Arch.  f.  Physiol.,  1880,  p.  1. 

*  Breuer  (J.).  "  Ueber  die  Selbststeuerung  der  Athmung  durch  den  Nervus 
vagus."    Centralbl.  f.  med.  Wissensch.,  1868,  p.  616. 

«Hering(E.).    /6iq!.,  1869,  p.  109. 

*  LangendorflF.  "  Ueber  die  Selbststeuerung  der  Athembewegungen."  Du  Bois- 
Reymond's  Arch.  f.  Physiol.  Suppl.  Band.,  1879,  p.  48. 

VOL.  L  O 


210  ELEMENTARY  AFFECTIONS   OF 

frequency  of  the  respiratory  movements  as  by  the  increasing  effort  required 
to  accomplish  the  act,  and  by  an  alteration  in  the  ratio  of  the  various 
stages  of  the  respiratory  rhythm. 

(3)  Apncea.—Bj  blowing  air  into  the  lung  or  by  forced  voluntary 
breathing  the  blood  becomes  saturated  with  oxygen  and  poor  in  carbonic 
acid,  and  the  respiratory  movements  are  temporarily  arrested.  This  condi- 
tion is  termed  apnosa. 

(4)  Asphyxia. — When  the  deficiency  of  oxygen  in  the  blood  is  very 
great  the  excitability  of  the  respiratory  motor  centre  in  the  medulla 
becomes  destroyed,  and  the  respiratory  movements  are  arrested.  This 
condition  is  termed  asphyxia. 

(5)  Cheyne-Stokes  Respiration. — In  varioixs  cerebral  and  cardiac  affec- 
tions the  breathing  becomes  intermittent.  After  a  prolonged  pause  the 
respiratory  rhythm  becomes  established  and  gradually  increases  until 
dyspnoea  is  produced,  when  the  breathing  gradually  sinks  until  the  next 
pause.  This  peculiar  kind  of  breathing,  with  its  gradually  ascending  and 
descending  intensity  and  periodical  pause,  is  named  the  Cheyne-Stokes 
respiration,  after  the  observers  who  first  described  it.  The  usual  explanation 
of  this  phenomena  is  that  when  the  excitability  of  the  respiratory  centre  is 
oreatly  diminished  the  blood  must  become  surcharged  with  carbonic  acid 
each  time  in  order  to  excite  it,  the  increased  inspiratory  effects  which  are 
thus  caused  diminishes  the  venous  state  of  the  blood,  and  the  respirations 
will  then  become  less  powerful,  and  are  finally  succeeded  by  a  temporary 
arrest  until  the  blood  becomes  again  surcharged  with  carbonic  acid.  It 
would  appear  from  Langendorff 's*  experiments  that  cutting  off  the  supply 
of  blood  to  the  medulla  will  induce  this  kind  of  breathing  in  animals,  and 
it  is  therefore  likely  that  the  disturbance  may  be  caused  by  an  alteration 
in  the  nutritive  quality  of  the  blood. 

(6)  Sneezing  and  Coughing.— Yoreign  bodies  and  pathological  products 
in  the  air  passages  irritate  the  mucous  membrane,  and  produce  by  reflex 
action  an  explosive  blast  of  air  by  which  they  are  expelled.  When  the 
nasal  mucous  membrane  is  irritated  the  air  is  driven  through  the  nose  and 
the  noise  caused  by  it  is  named  sneezing,  and  when  the  larynx  is  irritated 
the  air  is  driven  through  the  partially  closed  glottis  and  the  act  is  called 
coughing. 

(7)  Respiratory  Paralysis. — When  the  respiratory  centres  in  the  medulla 
are  injured  complete  respiratory  paralysis  ensues  and  death  soon  results, 
although  the  action  of  the  heart  may  be  maintained  for  an  indefinite  period 
if  artificial  respiration  be  resorted  to.  It  is  not,  however,  uncommon  to 
observe  partial  paralysis  in  disease.  A  pachymeningitis,  for  instance,  on  a 
level  with  the  third  and  fourth  cervical  vertebrae  may  produce  paralysis  of 
the  diaphragm  while  leaving  the  action  of  the  remaining  muscles  of  respira- 
tion imaffected.  In  a  case  of  haemorrhage  into  the  spinal  cord  in  the  lower 
cervical  and  dorsal  regions  under  my  care  there  was  at  first  complete 

'  LangendorfiE  und  Siebert.  "  Ueber  periodische  Athmung  bei  Froschen."  Du 
Bois-Keymond's  Archiv.,  1881,  p.  242. 


INDIVIDUAL  MOTOR  MECHANISMS. 


211 


paralysis  of  all  the  intercostal  muscles  on  both  sides  while  the  diaphragm 
was  unaffected.  After  a  time  the  intercostal  muscles  of  the  left  side 
recovered,  but  those  of  the  right  side  remain  permanently  paralysed. 

(8)  Respiratory  Spasm. — Spasm  of  the  muscles  of  respiration  occurs  in 
pleurisy  and  other  painful  affections,  and  an  intermittent  spasm  of  the 
diaphragm  is  the  cause  of  hiccough. 


Fig,  l<5. 


§  98.  Innervation  of  the  Bladder  and  Rectum. 

The  walls  of  the  bladder  and  rectum  contain  muscular  fibres  to  expel 
their  contents,  while  at  the  mouth  of  each  there  is  a  sphincter  which  is 
maintained  in  a  state  of  tonic  contraction,  and  thus  prevents  the  con- 
tinual escape  of  their  contents.  It  is  probable  that  the  nervous  arrange- 
ments for  the  regulation  of  both  the 
urinary  and  rectal  functions  are  the 
same,  and  it  wiU  consequently  suffice  if 
we  describe  the  nervous  mechanism  of 
the  bladder. 

This  nervous  mechanism  consists  of 
nerve  centres,  and  their  connections  with 
one  another  and  with  the  viscus.  It  is 
probable  that  two  centres  exist  in  the. 
spinal  cord  ;  an  automatic  centre  {Fig. 
16,  MS)  situated  in  the  segments  corre- 
sponding with  the  second,  third,  and 
fourth  sacral  nerves,  and  maintaining  the 
tonic  contraction  of  the  sphincter;  and 
a  reflex  centre  {Fig.  16,  MD)  situated  on 
a  little  higher  level  for  the  expulsion  of 
the  urine  by  inducing  a  contraction-  of 
the  detrusor  vesicae.  Another  centre  is 
situated  in  the  cortex  of  the  brain,  and 
by  its  means  the  automatic  and  reflex 
lumbar  centres  are  brought  under  volun- 
tary control.  The  cortical  centre  is 
connected  with  the  lumbar  centres  by 
means  of  centrifugal  fibres  (MT),  and  the 
lumbar  automatic  and  reflex  centres  are 
connected  with  the  bladder-  by  efferent 
fibres,  some  of  which  (m  *)  connect  the 
automatic  centre  (MS)  witkthe  sphincter, 
and  others  (m  d)  connect,  the  reflex  cen- 
tre with  the  detrusor.  These  centres  are 
also  connected  with  the  periphery  by 
means  of  afferent  fibres,  some  of  them 
being  reflex  and  others  sensory.     The 


Fig.  16  (after  Gowers).  Diagram 
showing  the  Probable  Plan  of  the 
Centre  for  Micturition.  —  MT, 
Motor  tract,  ST,  Sensory  tract 
in  the  spinal  cord ;  MS,  Centre, 
and  m  s,  Motor  nerve  for 
sphincter ;  MD,  Centre,  and 
m  d,  Motor  nerve  for  detrusor  ; 
s,  Afferent  nerve  from  mucous 
membrane  to  S,  sensory  portion 
of  centre;  B,  Bladder,  At  r 
the  condition  during  rest  is  indi- 
cated, the  sphincter  centre  in 
action,  the  detrusor  centre  not 
acting.  At  a  the  condition 
during  action  is  indicated,  the 
sphincter  centre  inhibited,  the 
detrusor  centre  acting. 


212  ELEMENTARY  AFFECTIONS  OF 

reflex  aflferent  fibres  (s)  ascend  from  the  mucous  membrane  of  the  bladder 
to  reach  the  lumbar  centres  through  the  posterior  grey  horns  (S),  while 
other  afferent  fibres  ascend  along  the  centripetal  conducting  paths  (ST) 
to  reach  the  cortex  of  the  brain,  and  then  to  become  connected  with  the 
cortical  centre. 

When  the  bladder  is  empty  or  only  partially  full  the  sphincter  is  main- 
tained in  a  state  of  continuous  contraction  by  the  action  of  the  automatic 
centre  (MS).  But  when  it  becomes  distended  a  strong  impression  is  made 
upon  the  afferent  nerves  of  the  mucous  membrane  and  impulses  are  con- 
veyed to  the  lumbar  centre  and  to  the  brain.  Now  the  effect  of  afferent 
impulses  upon  an  automatic  centre  is  to  inhibit  its  action,  while  afferent 
impulses  conveyed  to  a  reflex  centre  find  vent  along  efferent  channels. 
When,  therefore,  afferent  impulses  are  conveyed  to  the  lumbar  centres,  the 
action  of  the  automatic  centre  is  inhibited  and  the  sphincter  relaxes,  while 
that  of  the  reflex  centre  is  increased  and  the  detrusor  vesicae  contracts. 
The  action  of  the  local  automatic  and  reflex  mechanisms  is  rendered  more 
definite  and  certain  when  the  afferent  impulses  reach  the  brain.  A  desire 
to  urinate  is  excited ;  voluntary  impulses  are  then  conveyed  by  centrifugal 
channels  to  the  inferior  centres,  the  action  of  the  automatic  centre  is  either 
increased  and  that  of  the  reflex  centre  inhibited  so  as  to  check  the  reflex 
tendency  to  urinate,  or  the  action  of  the  automatic  centre  is  inhibited  and 
that  of  the  reflex  increased,  and  urination  is  accomplished. 

Disorders  of  the  Vesical  Nervous  Mechanism. 

The  nervous  mechanism  of  the  bladder  may  be  affected  in  various  ways, 
but  those  disorders  generally  declare  themselves  either  by  incontinence  or 
retention.  Affections  of  the  nervous  mechanism  of  the  bladder  may  be 
divided  into  those  caused  by  (a)  spino-peripheral  and  (6)  those  caused  by 
cerebro-spinal  lesions. 

(o)  Spino-peripheral  Lesions. — A  destructive  lesion  of  the  automatic 
centre  of  the  sphincter,  or  of  its  efferent  fibres,  gives  rise  to  paralytic  or 
atonic  incontinence,  while  irritative  lesions  occasion  spasmodic  retention. 
A  destroying  lesion  of  the  reflex  centre  causes  paralytic  or  atonic  retention, 
and  irritative  lesions  of  the  reflex  arc,  generally  caused  by  peripheral 
irritation  of  the  afferent  fibres,  as  in  cystitis,  give  rise  to  spasmodic 
incontinence. 

(6)  Cerebro-spinal  Lesions. — Destroying  lesions  of  the  cortical  centre  or 
of  the  centrifugal  conducting  paths  arrest  voluntary  control  over  the  bladder, 
the  urine  is  discharged  at  hregular  intervals,  and  cannot  be  restrained ;  but 
if  the  spino-peripheral  apparatus  is  free  from  disease,  the  urine  does  not 
escape  in  a  continuous  stream.  If  the  centripetal  cerebral  conducting 
paths  are  also  affected,  the  patient  is  unconscious  of  the  act  of  urination. 
Irritative  lesions  of  the  cerebro-spinal  apparatus  may  give  rise  at  one  time 
to  spasmodic  incontinence,  and  at  other  times  to  spasmodic  retention.  The 
disturbances  of  the  functions  of  the  bladder  met  with  in  cases  of  hysteria 


INDIVIDUAL  MOTOR  MECHANISMS.  213 

and  during  epileptic  attacks  are  probably  caused  by  cerebral  discharges 
along  the  cerebro-spinal  conducting  paths. 

Innervation  of  the  Genital  Organs. 

Sexual  Functions. — The  sexual  functions  are  governed  by  a  cortical 
centre,  a  reflex  centre  situated  in  the  upper  part  of  the  lumbar  enlarge- 
ment and  local  automatic  ganglia  connected  with  the  blood-vessels  of  the 
corpora  cavernosa.  It  is  not  necessary  to  describe  in  detail  the  connections 
of  these  centres  with  one  another  and  with  the  periphery.  The  lumbar 
reflex  centre  is  stimulated  to  action  by  (a)  irritation  of  the  sensory  nerves 
of  the  glans  penis,  and  {h)  discharge  from  the  cortex  of  the  brain  with  its 
associated  emotional  excitement.  On  stimulation  of  the  reflex  centre 
efferent  impulses  are  conveyed  along  the  nervi  erigentes,  which  cause 
vascular  dilatation  and  erection  by  inhibiting  the  action  of  the  local 
automatic  ganglia.  A  still  more  prolonged  irritation  of  the  lumbar  centre 
produces  ejaculation. 

Disorders  of  the  Sexual  Functions. 

The  sexual  functions  may  be  disordered  by  (a)  spino-peripheral,  or  {b) 
cerebro-spinal  lesions. 

(a)  Spino-peripheral  Lesions, — Destroying  lesions  of  the  lumbar  centre 
or  of  the  nervi  erigentes  cause  impotence ;  while  irritative  lesions  of  the 
reflex  arc,  generally  stimulation  of  the  afferent  portion  of  the  arc,  causes 
erection  without  sexual  desire,  named  priapism,  or  partial  erections  with 
strong  sexual  desire,  named  satyriasis.  In  the  latter  condition  the  cortical 
centres  are  also  stimulated  either  directly  from  the  original  source  of  irri- 
tation or  indirectly  from  the  erections  produced.  This  condition  is  met 
with  in  cases  of  locomotor  ataxia. 

(b)  Cerehro- Spinal  Lesions. — Destroying  lesions  of  the  cortical  centres 
or  of  the  centrifugal  conducting  paths  render  the  patient  impotent,  but 
erections  and  ejaciilations  may  still  occur  so  long  as  the  reflex  mechanism 
in  the  cord  is  intact.  If  the  centripetal  paths  are  interrupted  the  subject 
is  insensible  of  an  erection.  The  act  of  coition,  for  instance,  affords  no 
pleasure  to  many  hysterical  women,  and  it  is  probable  that  in  them  there 
is  a  functional  arrest  of  centripetal  impulses  to  the  cortex  of  the  brain. 
Irritative  lesions  of  the  cortical  centre  or  of  the  centrifugal  conducting  path 
may  give  rise  to  satyriasis,  nymphomania,  or  to  priapism.  Satyriasis  in 
the  male,  or  nymphomania  in  the  female,  are  not  unfrequently  observed  in 
the  insane,  caused  probably  by  irritation  of  the  cortex,  and  irritation  of 
centripetal  fibres  is  also  likely  to  give  rise  to  the  same  condition.  But 
although  irritation  of  centrifugal  channels  occasions  priapism,  it  is  not 
likely  to  cause  satyriasis.  Lesions  in  the  upper  dorsal  and  lower  cervical 
regions  of  the  cord  are  often  accompanied  by  priapism,  doubtless  caused  by 
irritation  of  centrifugal  conducting  paths. 


214  ELEMENTARY  AFFECTIONS  OF 

§  99.  Innervation  of  the  other  Viscera. 

It  would  occupy  too  much  space  to  enter  upon  a  similar  analysis  of  the 
motor  affections  of  the  other  viscera,  as  the  various  segments  of  the  intes- 
tines, and  the  uterus  with  its  appendages.  Comphcated  affections  of  these 
and  other  organs  occm"  from  lesions  of  the  centres  of  innervation  in  the 
cortex  of  the  brain,  medulla  oblongata,  and  spinal  cord,  as  well  as  from 
lesions  of  the  intramural  nerve  centres,  and  the  fibres  which  connect  these 
different  centres  with  one  another  and  the  periphery.  These  lesions  give 
rise  to  spasm  or  paralysis,  or  to  disorders  of  co-ordination  similar  in  prin- 
ciple to  the  disturbances  of  the  nervous  mechanisms  we  have  just  been 
considering.  The  nervous  mechanism  which  regulates  the  movements  of 
the  iris,  and  the  disturbances  caused  by  lesions  of  it,  will  be  considered 
along  with  the  motor  disorders  of  the  eye, 

(III.)-VASO-MOTOR  DISTURBANCES   (VASCULAR   KINESIONEU- 
ROSES,   OR  ANGIONEUROSES). 

The  calibre  of  the  blood-vessels  throughout  the  body  appears 
to  be  regulated  by  means  of  a  nervous  mechanism  similar  in  all 
essential  respects  to  that  which  regulates  the  movements  of  the 
hollow  viscera.  The  middle  coat  of  all  arteries  contains  circu- 
larly disposed  smooth  fibres,  which  become  relatively  more 
abundant  in  the  smaller  arteries,  and  contraction  of  which 
diminishes  the  calibre  of  the  vessels.  Nerve  fibres  belonging 
to  the  sympathetic  system  are  freely  distributed  to  the  blood- 
vessels, and  it  is  assumed  that  numerous  excito -motor  gan- 
glionic elements  exist  in  the  plexus  which  surrounds  the  vessels, 
forming  local  vaso-motor  mechanisms.  The  local  ganglia,  along 
with  the  fibres  passing  from  them  to  terminate  in  the  mus- 
cular fibres,  form  a  simple  co-ordinating  vascular  mechanism, 
or,  in  the  language  of  Meynert,  a  projection  system  of  the  third 
order.  These  local  ganglia  are  supposed  to  be  connected  with 
vaso-motor  centres  in  the  spinal  cord  and  medulla  oblongata  by 
two  kinds  of  fibres,  but  the  conducting  paths  in  the  cerebro- 
spinal and  sympathetic  nerves  are  not  yet  clearly  made  out  in 
all  cases.  Irritation  of  the  one  kind  of  fibres  excites  the  local 
ganglia  to  increased  activity,  and  consequently  induces  contrac- 
tion of  the  muscular  coat ;  hence  they  are  called  vaso-constrictor 
fibres ;  while  irritation  of  the  second  kind  arrests  the  action  of 
the  ganglia,  and  consequently  paralyses  the  muscular  coat  and 
dilates  the  vessels,  and  hence  they  are  called  vaso-dilator  fibres. 


INDIVIDUAL  MOTOR  MECHANISMS.  215 

THe  va^so^motor  centres  in  the  cord  and  medulla  oblongata,  along 
with  the  fibres  which  connect  them  with  the  local  ganglia,  form 
a  compound  co-ordinating  vascular  mechanism,  the  fibres,  in  the 
language  of  Meynert,  forming  a  projection  system  of  the  second 
order.  During  health  the  action  of  this  nervous  mechanism  is 
so  balanced  that  the  vessels  are  maintained  in  a  medium  but 
variable  degree  of  contraction,  which  constitutes  the  vascular 
tonus.  The  arterial  tonus  throughout  the  body  is  maintained 
and  regulated  by  means  of  a  general  vaso-motor  centre  situated 
in  the  upper  part  of  the  medulla  oblongata.  From  this  centre 
vaso-motor  fibres  pass  to  the  various  vascular  areas  of  the  body, 
partly  through  the  rami  communicantes  and  sympathetic 
system,  and  partly  through  the  anterior  roots  and  spinal  nerves. 
It  has  been  proved  that  afferent  impulses  from  various  parts  of 
the  body  may  exalt  or  depress  the  arterial  tone  by  constricting 
or  dilating  either  the  whole  vascular  system  or  particular  vas- 
cular areas.  It  is  manifest  that  a  mutual  antagonism  must 
exist  between  the  local  and  general  effect  on  the  circulation,  by 
constriction  or  dilatation  of  a  particular  vascular  area.  If  a 
particular  vessel  is  constricted,  the  area  to  which  it  is  dis- 
tributed is  less  freely  supplied  with  blood,  the  tissues  become 
blanched,  and  the  temperature  falls ;  but  provided  the  condition 
of  the  heart  continue  the  same,  there  will  be  an  increased  flow 
of  blood  through  the  other  arteries  of  the  body,  and  the  general 
arterial  pressure  will  be  augmented ;  while  the  converse  of  this 
holds  good  when  an  artery  is  dilated. 

The  local  and  general  effect  produced  may  be  illustrated  by 
stimulating  with  the  interrupted  current  the  central  end  of  the 
divided  depressor  nerve,  which  in  some  animals,  as  the  rabbit,  is 
a  separate  branch  of  the  vagus  running  alongside  the  carotid 
artery  and  sympathetic  nerve,  while  the  arterial  pressure  in  the 
carotid  artery  is  being  registered.  When  the  central  end  of  the 
nerve  is  stimulated  a  marked  fall  of  the  pressure  in  the  carotid 
artery  is  observed ;  but  when  the  splanchnic  nerves  are  previously 
divided  the  fall  is  very  slight,  showing  that  the  greater  part  of  the 
effect  had  been  produced  by  dilatation  of  the  intestinal  arteries 
caused  by  irritation  of  the  depressor  nerve.  The  afferent  im- 
pulses reaching  the  vaso-motor  centre  through  the  depressor 
nerve  either  depress  or  inhibit  a  portion  of  that  centre,  or  irritate 


216  ELEMENTARY  AFFECTIONS   OF 

that  portion  of  it  which  is  connected  with  the  local  ganglia  by 
vaso-dilator  fibres.  Irritation  of  the  central  end  of  the  'pressor 
fibres,  which  are  found  in  the  cervical  sympathetic  nerve  as 
well  as  in  the  vagus,  raises  the  general  arterial  pressure  by 
contracting  the  intestinal  arteries.  Stimulation  of  almost  any 
afferent  nerve  affects  the  blood  pressure,  even  when  the  heart's 
beat  remains  unchanged.  A  medium  degree  of  irritation  of  the 
peripheral  nerves,  especially  the  cutaneous  sensory  nerves,  causes 
an  increase,  while  strong  irritation  causes  great  diminution  of 
the  arterial  tonus.  It  is  very  probable  that  the  vaso-motor 
centre  must  be  regarded  as  a  reflex  and  not  as  an  automatic 
centre ;  and  it  is  likely  that  the  afferent  fibres  of  the  reflex 
arc  pass  upwards  in  the  lateral  columns  of  the  cord ;  at  least  the 
experiments  of  Miescher  and  Nawrocki^  appear  to  prove  that  the 
afferent  fibres  of  the  reflex  arc  for  the  posterior  extremities  in 
the  rabbit  occupy  this  position  in  the  lumbar  portion  of  the 
spinal  cord.  But,  although  the  centre  in  the  medulla  oblongata 
is  the  general  vaso-motor  centre  for  all  the  arteries  of  the  body, 
subordinate  centres  appear  to  exist  throughout  the  length  of  the 
spinal  cord ;  at  least  the  experiments  of  Goltz  and,  more  recently, 
those  of  Strieker,  have  proved  that  such  centres  exist  in  the 
lower  portions  of  the  cord. 

Recent  experiments  have  shown  that  the  vaso-motor  centre  in 
the  medulla  is  connected  with  certain  definite  regions  in  the 
cortex  of  the  brain ;  these  connecting  paths  constituting  a 
vascular  projection  system  of  the  first  order.  Budge  found  that 
irritation  of  the  crus-cerebri  induced  arterial  contraction,  and 
similar  observations  have  been  made  in  various  pathological 
conditions.  Eulenburg  and  Landois^  have  proved  that  definite 
regions  of  the  cortex  of  the  brain  in  dogs,  corresponding  to  the 
central  convolutions  in  man,  constitute  vaso-motor  centres  for 
the  extremities  of  the  opposite  side  of  the  body.  These  vaso- 
motor centres  are  situated  in  the  vicinity  of  the  voluntary  motor 
centres  of  the  cortex,  and  destruction  of  them  with  the  actual 

•  See  Hoffmann  und  Schwalbe.  Jahresb,  der  Anat.  und  Physiol.  Bd.  I.,  1873, 
p.  516. 

*  Eulenburg  und  Landois.  "  Die  thermischen  Wirkungen  localisirter  Reizung 
und  Zerstorung  der  Grosshirnoberflache."  Virchow's  Archiv.,  LXVIII.,  1876, 
p.  245.  See  also  Hitzig  (E.)-  " Ueber  Erwarmung  der  Extremitaten  nach  Gross- 
himverletzungen."    Centralbl.  f.  med.  Wissensch.,  1876,  p.  323. 


INDIVIDUAL  MOTOR  MECHANISMS.  217 

cautery  leads  to  a  more  or  less  enduring  increase  of  temperature 
in  the  extremities  of  the  opposite  side.  These  centres,  then, 
when  acting  upon  the  inferior  centres,  constitute  double  com- 
pound vaso-motor  centres,  and  their  existence  explains  the 
frequency  with  which  vaso-motor  disturbances  are  associated 
with  the  most  various  cerebral  diseases. 

§  100.  Varieties  of  Vascular  Motor  Disturbances. — Vascular 
motor  disturbances  may  be  subdivided  into  those  which  are 
caused  by  excess,  and  diminution  or  abolition  of  motor  innerva- 
tion ;  the  former  giving  rise  to  contraction  of  the  arterial  walls  or 
to  hyperkinesis  of  the  vessels ;  while  the  latter  causes  dilatation 
of  the  vascular  walls,  or  akinesis  of  the  vessels.  The  first  con- 
dition may  also  be  called  Angiospasmi,  and  the  second  Angio- 
paresis  and  Angioparalysis.  From  what  has  already  been  said 
with  respect  to  the  existence  of  both  vaso-constrictor  and  vaso- 
dilator nerve  fibres,  it  is  evident  that  contraction  and  dilatation 
of  the  vessels  may  arise  from  very  different  conditions ;  and  that 
the  latter  condition  is  not  always  to  be  regarded  as  a  truly 
paralytic  symptom.  Affections  of  the  vessels  may  arise  from 
lesions  either  in  the  territory  of  the  peripheral,  spinal,  or  cerebral 
portions  of  the  nervous  system. 

(1)  Peripheral  Angioneuroses. — 'Lesions  of  the  peripheral 
nervous  system  and  its  connected  ganglia  give  rise  to  both 
spasmodic  and  paralytic  affections  of  the  vessels.  The  disorders 
of  innervation  may  be  of  direct  or  reflex  origin. 

The  refles  disorders ,  may  be  produced  by  lesion  of  the  aflferent  fibres 
which  pass  from  the  vessels  to  the  intramural  ganglia  in  the  vascular  walls, 
or  of  the  afferent  branches  from  other  parts  of  the  organ  to  one  or  more  of 
the  ganglia  situated  higher  up.  Both  spasm  and  paralysis  of  the  vessels 
may  be  produced  in  a  reflex  manner,  although  it  is  not  known  under  what 
conditions  the  one  or  the  other  state  is  caused  ;  and  these  conditions  are 
doubtless  frequently  active  in  producing  local  nutritive  changes  in  organs, 
or  in  aggravating  affections  already  existing.  After  injury  of  the  peripheral 
nerves,  especially  after  complete  division  of  the  large  nerve-trunks  of  the 
extremities,  paralysis  and  anaesthesia  are  always  associated  with  redness 
and  increased  temperature  of  the  affected  extremities,  which  depend  upon 
paralysis  of  the  vaso-constrictors,  and  not  upon  irritation  of  the  vaso- 
dilators. With  degeneration  of  the  peripheral  portion  of  the  injm-ed  nerve, 
trophic  changes  occur  in  the  affected  extremity,  the  circulation  becomes 
less  active,  the  material  exchanges  are  diminished,  and  less  local  heat  is 


§W  ELEMENTARY  AFFECTIONS  OF 

generated,  while  owing  to  the  dilatation  of  the  superficial  vessels  more-' 
heat  is  radiated ;  hence  the  temperature  of  the  limb  falls  below  the. 
healthy  standard.  .     , 

(2)  Spinal  Angioneuroses. — Lesions  of  the  vaso-motor  centres 
in  the  cord  and  medulla  oblongata,  and  of  the  associated  centri- 
fugal sympathetic  and  cerebro-spinal  conducting  paths,  either 
increase  or  diminish  the  tonic  innervation,  which  in  health  is 
constantly  passing  to  the  vessels ;  hence  the  resulting  vascular 
affections  may  be  regarded  as  hypertony  and  atony,  and  not  as 
true  spasm  and  paralysis. 

The  vascular  disturbance  may  be  produced,  either  directly  or  in  a  reflex 
manner,  from  different  parts  of  the  periphery.  The  vascular  tonus  may  in. 
this  reflex  manner  be  either  increased  or  diminished  for  the  whole  or  for  a 
part  only  of  the  vascular  system.  Hypertony  or  atony  of  the  blood-vessels 
may,  therefore,  result  not  only  from  lesions  of  the  spinal  cord  and  medulla 
oblongata,  the  nerve  roots,  rami-commimicantes,  sympathetic  system  and 
its  peripheral  branches,  and  the  cerebro-spinal  nerves  ;  but  also  from  aflfec- 
tions  of  the  skin  or  of  the  parenchymatous  viscera.  Whether  the  vascular 
affection  is  diffused  over  the  whole  vascular  system,  or  hmited  to  larger  or 
smaller  vascular  territories,  depends  upon  the  position  of  the  primary  lesion 
as  well  as  upon  the  dm-ation  and  intensity  of  the  reflex  irritation.  Even 
the  quahty  of  the  vascular  affection  depends  upon  the  degree  and  duration' 
of  the  primary  irritation.  A  feeble  local  irritation  of  the  skin  gives  rise  to 
momentary  contraction  of  the  vessels  in  the  vicinity,  with  local  diminution 
of  temperature,  soon  followed  by  local  vascular  dilatation  with  increased 
temperature.  Strong  cutaneous  irritation  acting  on  a  large  siu-face  pro-, 
duces  a  considerable  diminution  of  temperature,  not  simply  of  the  surface, 
but  also  of  the  internal  organs  as  measured  by  the  temperature  in  the 
rectum.  This,  no  doubt,  depends  upon  contraction  of  the  vessels  caused 
by  reflex  irritation  of  the  vaso-motor  centres  in  the  spinal  cord  and  medvilla 
oblongata. 

Injuries  and  diseases  of  the  spinal  cord  which  cause  paraplegia  are  not 
unfrequently  associated  with  primary  increase  of  the  temperature  of  the 
paralysed  parts,  followed  by  a  diminution  of  temperatm-e  when  degenerative 
changes  occur  in  the  peripheral  nerves  below  the  seat  of  the  lesion  and  in 
the  muscles  supplied  by  them.  Injuries  of  the  cord  which  give  rise  to 
spinal  hemiplegia  are  often  accompanied  by  a  primary  increase  of  tempera- 
ture of  the  paralysed  side.  This  primary  increase  is  especially  weU  marked 
in  injuries  of  the  cervical  portion  of  the  cord  near  the  medulla  oblongata, 
but  even  this  increase  is  generally  followed  by  a  corresponding  diminution 
of  temperature  before  death.  In  some  cases,  however,  instead  of  a  fall  of 
temperature  before  death,  it  continues  to  rise  after  the  injury,  and  may 
even  increase  considerably  after  death.     This  remarkable  rise  of  tempera- 


INDIVIDUAL  MOTOR  MECHANISMS.  219 

ture  probably  depends  upon  sudden  paralysis  of  the  whole  vaso-motor 
system,  or  upon  interference  with  the  action  of  a  heat-regulating  centre  in 
the  medulla  oblongata. 

(3)  Cerebral  Angioneuroses. — Cerebral  lesions  of  the  cortical 
vaso-motor  centres  and  of  the  conducting  paths  which  connect 
them  with  the  vaso-motor  centre  in  the  medulla  give  rise  to 
various  vascular  disturbances.  The  pallor  of  fear  and  the  blush 
of  shame  are  most  probably  produced  by  a  motor  discharge  from 
the  cortex  acting  upon  the  vaso-motor  centre  in  the  medulla. 

It  is  also  probable  that  many  cases  of  unilateral  hsemidrosis  and  ephi- 
drosis,  as  well  as  certain  vascular  affections  in  hemicrania,  Graves'  disease, 
epilepsy,  hysteria,  and  mental  diseases,  must  be  regarded  as  direct  or  reflex 
psychomotor  angioneuroses. 

Paralysis  of  cerebral  origin,  as  hemiplegia  resulting  from  an  apoplectic 
attack,  is  generally  associated  with  a  slight  elevation  of  temperature  of  the 
paralysed  parts,  which  is  almost  never  beyond  1°  C.  The  normal  tem- 
perature is  very  rarely  maintained,  and  a  fall  of  temperature  is  still  rarer. 
In  long-standing  cases  of  hemiplegia  the  temperature  falls  to  the  normal 
standard  or  may  even  sink  below  it.  In  fatal  cases  the  temperatm-e  of  the 
two  sides,  as  a  rule,  becomes  equal  before  death,  but  at  times  the  temperatiu-e 
of  the  paralysed  side  cools  sooner  than  the  other  after  death.  In  old- 
standing  cases  the  pulse  on  the  paralysed  is  often  smaller  and  more  com- 
pressible than  on  the  healthy  side;  and  the  paralysed  hand  and  foot  is 
whiter  and  colder  than  the  corresponding  parts  of  the  other  side.  In  some 
cases  of  cerebral  paralysis  the  increase  of  temperature  on  the  paralysed  side 
persists  for  a  relatively  long  time,  and  in  them  it  is  probable  that  this 
increase  depends  upon  paralysis  of  the  vaso-motor  cortical  centres,  or  an 
interruption  of  the  centrifugal  conducting  paths  between  these  and  the 
centre  in  the  medulla. 

§  101.  Cutaneous  Angioneuroses. — Diffused  pallor  and  red- 
ness of  the  skin — the  former  caused  by  increase  and  the  latter 
by  diminution  of  the  normal  tonic  innervation  of  the  smaller 
superficial  arteries — may  be  observed  both  in  normal  and  ab- 
normal conditions  of  the  nervous  system.  Examples  of  diffused 
cutaneous  pallor  and  redness  may  be  observed  under  the  action 
of  various  emotions,  as  fear  and  shame  ;  while  sudden  pallor  is 
associated  with  fainting,  and  alternating  conditions  of  pallor 
and  redness  may  be  observed  in  various  neuroses,  as  hysteria 
and  epilepsy.  ' 

Some  parts  of  the  body  may  present  vascular  dilatation  with  increased 
temperature  and  secretion,  while  other  portions  present  the  opposite  con- 


220  ELEMENTARY  AFFECTIONS  OF 

ditions  of  vascular  contraction,  diminislied  temperature  and  secretion.  In 
epileptic  and  hysterical  attacks  the  countenance  may  be  flushed  and  covered 
with  sweat,  while  the  extremities  are  blanched  and  cold.  These  phenomena 
may  at  times  be  limited  to  one  half  of  the  body,  as  in  many  cases  of  epileptic 
aura,  and  are  not  unfrequently  associated  with  corresponding  changes  and 
fluctuations  in  the  pulsation  of  the  larger  superficial  arteries.  In  these 
cases  the  reddened  portions  may  become  quickly  blanched,  and  conversely 
the  pallid  parts  may  become  quickly  reddened.  Blushing  is  one  of  the 
most  interesting  vaso-motor  phenomena,  and  a  similar  vascular  condition 
may  be  closely  simulated  by  the  inhalation  of  nitrite  of  amyl.  Blushing 
is,  as  Darwin  remarks,  of  all  expressions  the  most  human.  The  lower 
animals  do  not  blush ;  neither  does  the  human  infant.  Idiots  rarely  blush, 
but  the  insane  are  sometimes  particularly  liable  to  blushing  (Crichton- 
Browne).  Women  and  children  blush  more  than  men;  and  the  vessels  of 
the  face  become  dilated  from  the  emotion  of  shame  in  almost  all  the  races 
of  men,  though  in  the  very  dark  races  no  distinct  change  of  colour  can  be 
perceived  (Darwin).  The  face,  ears,  and  neck  are  the  parts  which  redden 
in  most  cases,  but  in  some  sensitive  people  the  redness  extends  to  the 
upper  part  of  the  chest;  and  Difienbach  mentions  the  case  of  a  lady  in 
whom,  during  exposure  for  surgical  examination,  the  blush  extended  over 
the  nates.  Blushing  may  occm"  in  disseminated  patches,  as  in  the  case  of  a 
mother  and  daughter  described  by  Sir  James  Paget,  in  whom  "  a  big  splash 
of  red  appeared  first  on  one  cheek,  and  then  other  splashes  variously  scat- 
tered over  the  face  and  neck."  Most  persons  when  blushing  deeply  manifest 
considerable  mental  confusion,  a  fact  which  appears  to  indicate  that  the  cere- 
bral circulation  is  simultaneously  afiected.  Pallor  is  sometimes  caused  under 
conditions  which  would  usually  induce  a  blush.  "  A  young  lady  told  me," 
says  Mr.  Darwin,  "  that  in  a  large  and  crowded  party  she  caught  her  hair 
so  firmly  on  the  button  of  a  passing  servant,  that  it  took  some  time  before 
she  could  be  extricated ;  from  her  sensations  she  had  imagined  that  she 
had  blushed  crimson,  but  was  assured  by  a  friend  that  she  had  turned 
extremely  pale."^  Converse  facts  have  also  been  observed,  in  which  the 
face  has  become  flushed  under  conditions,  such  as  sudden  fright,  which 
usually  induce  pallor  (Eulenburg).  The  tendency  to  blushing  is  inherited, 
and  Darwin,  on  the  authority  of  Burgess,  mentions  the  case  of  a  family, 
consisting  of  a  father,  mother,  and  ten  children,  all  of  whom,  without 
exception,  were  prone  to  blush  to  a  most  painful  degree. 

Various  vaso-motor  anomalies  occur  in  fevers.  The  initial  rigor  of 
various  acute  diseases  and  the  subsequent  warm  and  moist  surface, 
especially  in  intermittent  fever,  appear  to  be  caused  by  a  primary  con- 
traction and  secondary  dilatation  of  the  cutaneous  arteries. 

Local  Ancemia  and  Hypercemia  of  the  Skin  may  be  caused 
by  a  direct  or  reflex  local  irritation  of  the  surface,  such  as 

'  Expression  of  the  Emotions  in  Man  and  Animals,  by  Charles  Darwin,  M.A., 
F.B,.S.    1872.    p.  312  a  seq. 


INDIVIDUAL  MOTOR  MECHANISMS.  221 

atmospheric  influences,  local  application  of  cold,  and  various 
mechanical,  chemical,  and  electrical  irritants.  Besides  many 
cases  of  circumscribed  vaso- motor  aura  in  epilepsy  as  those 
described  by  Nothnagel^  on  the  extremities,  the  circumscribed 
patches  occurring  on  the  hands  and  forearms  of  washerwomen 
may  be  mentioned,  in  which  there  is  sudden  pallor  and  coldness 
of  the  affected  portion  of  skin,  along  with  diminution  of  sensi- 
bility. These  patches  may  at  times  be  observed  in  the  region 
of  distribution  of  a  single  nerve  as  the  median,  and  are  not 
unfrequently  associated  with  trophic  affections,  as  roseola  and 
urticaria  (Eulenburg).  A  curious  case  of  what  he  regards  as  a 
vaso-motor  neurosis  of  the  skin  is  reported  by  Appenrodt^  as 
occurring  in  a  healthy  boy  of  thirteen  years  of  age.  The  affection 
began  suddenly  about  the  nose  with  redness,  swelling  of  the 
skin,  severe  burning  pain,  and  was  at  first  like  the  early  stage 
of  erysipelas,  eczema,  or  erythema  exsudativum.  It  spread  in 
streaks  and  spots  over  the  nose,  forehead,  and  chin,  and  once, 
patches  appeared  on  the  breast.  These  patches  were  always 
sharply  defined,  and  symmetrically  placed  on  the  two  sides. 
The  patient  had  six  attacks  of  this  curious  affection  in  two  years, 
and  for  which  no  cause  could  be  assigned. 

What  has  been  described  under  the  name  of  Cerebral  Maculae 
(Taches  Cerebrales  of  Trousseau*)  consist  of  scattered  red  blotches 
and  mottlings  on  the  chest  or  abdomen  of  epileptics,  and  those 
suffering  from  Graves'  disease  and  other  neuroses.  When  the 
affected  portion  of  skin  is  rubbed,  or,  in  strongly-marked  cases, 
is  merely  touched  by  the  finger,  the  surface  soon  becomes  suffused 
with  bright  red  marks,  which  spread  to  some  distance  around  the 
point  touched,  and  persist  for  several  minutes. 

Tabetic  Ecchymoses. — Patches  of  discoloured  skin,  correspond- 
ing in  every  respect  to  the  ecchymoses  caused  by  a  blow,  have 
been  described  by  Straus*  as  occurring  in  locomotor  ataxy. 
These  patches  are  at  first,  according  to  the  statements  of  the 

'  Nothnagel.  "Zur  Lehre  von  den  vasomotorischen  Neurosen."  Deutsches 
Archiv.  f.  klin.  Med.     Bd.  II.,  1846,  p.  173. 

*  Deutsches  Med.  Wochenschr.,  1880,  No.  15.  Abstr.  Centralbl.  f .  Med.  Wissen- 
schaft.    Bd.  XVIII.,  1880,  p.  576. 

'  Trousseau.  Lectures  on  Clinical  Medicine,  translated  by  P.  V.  Bazire.  1868. 
Vol.  I.,  p.  48. 

"Straus  (J.).  "Des  Ecchymoses  Tab^tiques,  a  la  suite  des  crises  de  douleurs 
fulgurantes."    Archiv.  de  Neurologie.    Tome  I.,  1880-1,  p.  536. 


222  ELEMENTARY  AFFECTIONS   OF 

patients,  of  a  bright  red  colour,  but  soon  become  purple  and 
pass,  like  ordinary  ecchymoses,  through  various  shades  of  brown, 
green,  and  yellow,  until  they  finally  fade  from  the  circumference 
towards  the  centre,  and  disappear  from  four  to  six  days  from 
their  commencement.  These  ecchymoses  appear  suddenly 
towards  the  termination  of  severe  paroxysms  of  lancinating 
pains  and  gastric  crises.  They  are  irregularly  circular  in  form, 
and  vary  from  the  size  of  a  lentil  to  that  of  a  two  or  even  a  five 
franc  piece.  They  are  usually  found  scattered  over  the  lower 
extremities  and  lower  part  of  the  trunk,  their  situation  corre* 
sponding  to  the  foci  of  severest  pain.  They  vary  in  number, 
but,  as  a  rule,  several  of  them  are  found  at  the  same  time,  as 
many  as  three  or  four  of  them  being  observed  on  each  lower 
extremity.  The  local  asphyxia  of  Raynaud  belongs  most 
probably  to  the  angioneuroses ;  but,  as  it  frequently  terminates 
in  gangrene,  its  description  will  be  found  amongst  the  tropho- 
neuroses. 

§  102.  Visceral  Angioneuroses. — The  vaso-motor  nerves  of 
the  thoracic  and  abdominal  vessels  are  in  great  part  found  in 
the  plexuses  of  the  sympathetic.  The  vaso-motor  nerves  of  the 
thoracic  viscera  are  derived  from  the  inferior  cervical  and 
superior  thoracic  ganglia;  and  from  the  spinal  cord  by  com- 
municating branches  between  the  third  and  seventh  dorsal 
vertebrse.  The  vaso-motor  nerves  of  the  abdominal  viscera,  on 
the  other  hand,  exist  chiefly  in  the  splanchnic  nerves,  but  the 
stomach  appears  to  be  supplied  with  some  fibres  from  the  vagus. 
The  splanchnic  nerves  are  three  in  number — the  greater,  the 
lesser,  and  the  smallest — and  all  of  them  arise  from  the  thoracic 
ganglia  of  the  sympathetic.  The  first  takes  its  origin  from  the 
fifth  to  the  tenth  ganglia  and  the  second  from  the  tenth  to  the 
eleventh,  and  those  appear  to  supply  chiefly  the  stomach,  liver, 
spleen,  pancreas,  and  intestines.  The  third  arises  from  the 
twelfth  thoracic  ganglion,  and  it,  along  with  some  fibres  from 
the  lesser  nerve,  disappears  in  the  plexus  passing  to  the  kidneys. 
Section  of  the  splanchnic  nerves  occasions,  according  to  V.  Bezold, 
a  great  diminution  of  the  arterial  pressure  depending  upon 
great  dilatation  of  the  vessels  and  consequent  engorgement  of 
the  abdominal  viscera.     Irritation  of  the  distal  end,  on  the  other 


INDIVIDUAL  MOTOR  MECHANISMS.  223 

hand,  causes  contraction  of  these  vessels,  and  elevation  of  blood 
pressure  generally.  According  to  the  experiments  of  Rossbach 
and  Quellhorst^  it  must  be  assumed  that  a  part  of  the  vaso- 
motor nerves  of  the  abdominal  viscera  pass  in  the  vagus.  These 
authors  have  shown  that  irritation  of  the  peripheral  end  of 
the  divided  vagus  causes  considerable  increase  of  the  arterial 
pressure  in  the  abdominal  vessels,  even  after  paralysis  of  the 
intracardial  terminations  of  the  vagus  has  been  produced  by 
atropine. 

Brown-Sdquard^  has  shown  that  experimental  injury  of  the  lumbar 
portion  of  the  spinal  cord  in  guinea-pigs  sometimes  causes  congestion  of 
and  occasionally  even  extravasation  of  blood  in  the  suprarenal  capsules. 
In  a  case  of  acute  partial  myelitis,  observed  by  Bouchard  and  Bdhier, 
besides  the  usual  phenomena,  fresh  hsemorrhagic  foci  were  foimd  in  the 
substance  of  the  suprarenal  capsules.  Schiff,  Brown-Sequard,  and  other 
experimentalists  found  after  destruction  of  the  pons  and  basal  gangUa  the 
frequent  occurrence  of  hypersemia  and  ecchymoses  in  the  lungs,  pleurae, 
kidneys,  and  in  the  mucous  membrane  of  the  stomach  and  bowels.  Crushing 
or  section  of  one  half  of  the  pons  causes,  according  to  Brown-Sequard, 
hsemorrhages  into  the  lung  of  the  opposite  side.  The  paths  through  which 
these  influences  traverse  are  not  the  vagi,  but  the  sympathetic  system  and 
its  spinal  communications.  Brown-Sequard  also  found  hsemorrhage  in 
the  stomach  after  destruction  of  the  pons  at  the  level  of  the  peduncles  of 
the  cerebellum.  Eulenburg  found  intestinal  haemorrhage  after  burning 
of  the  upper  surface  of  the  posterior  division  of  the  cortex  of  the  brain  in 
a  dog,  although  he  regards  the  connection  between  the  two  as  being  some- 
what doubtful.  Congestion  and  extravasations  of  blood  in  the  internal 
organs  are  not  uncommon  in  association  with  hemiplegia;  either  in  con- 
sequence of  extravasation  of  blood  or  from  softening.  Charcot  mentions  a 
case  of  left-sided  apoplectic  hemiplegia  from  extravasation  of  blood  into 
the  right  corpus  striatmn,  in  which  ecchymoses  were  found  in  the  plem-ae, 
endocardium,  and  in  the  mucous  membrane  of  the  stomach  ;  while  the 
Galea  aponeiu-otica  of  the  paralysed  side  assumed  a  wine-red  colour,  and 
showed  several  ecchymoses. 

The  various  menstrual  disorders  which  are  so  frequently  associated  with 
emotional  distiu-bances  are  no  doubt  the  result  of  functional  disorders  of 
the  vaso- motor  nerves  in  different  parts  of  their  com'se  in  connection  with 
general  nervous  affections,  such  as  hysteria.  It  is  also  probable  that  many 
of  the  vicarious  hsemorrhages  of  the  stomach,  intestines,  lungs,  and  other 
organs  depend  upon  disorder  of  the  vaso-motor  innervation. 

'  Centralbl.  f.  med.  Wiesensch.    Bd.  XXIV.,  1876,  p.  740. 

"Experimental  Researches  applied  to  Physiology  and  Pathology,  by  Brown- 
Sequard.     New  York.    1853.     p.  13. 


224  ELEMENTARY  AFFECTIONS  OF 

§  103.  Secretion  of  Urine. — Certain  changes,  both  quantita- 
tive and  qualitative,  in  the  condition  of  the  urine,  such  as 
abnormal  increase  or  diminution  of  its  quantity,  the  presence  of 
abnormal  constituents,  as  albumen,  must  also  be  often  attri- 
buted to  affections  of  the  vaso-motor  nerves  of  the  kidneys. 

Bernard  places  the  vaso-motor  centre  of  the  kidneys  in  the  upper  part 
of  the  floor  of  the  fom-th  ventricle,  and  he  has  found  that  injiu-y  of  this 
part  causes  polyuria  and  albuminuria,  while  injxu-y  of  the  lower  part  of  the 
floor  of  the  ventricle  causes  temporary  glycosuria.  Various  derangements 
of  the  virjaary  secretion  are  not  imcommonly  observed  after  cerebral 
haemorrhage,  or  during  the  growth  of  cerebral  tumours,  and  these  anomahes 
are  peculiarly  liable  to  occur  in  haemorrhage  of  the  pons.  The  occurrence 
of  diabetes  melhtus,  and  insipidus,  in  consequence  of  lesion  of  the  nervous 
system,  is  of  pecuhar  interest.  The  primary  lesion  in  these  cases  may  be 
of  cerebral,  spinal,  or  peripheral  origin. 

§  104.  Glycosuria. — Bernard  first  observed  that  injury  of  a 
circumscribed  portion  of  the  fourth  ventricle  is  followed  by  the 
presence  of  sugar  in  the  urine,  and  Schiff^  attributed  the  result 
to  consecutive  paralysis  of  the  vaso-motor  centre. 

Recent  researches  have  shown  that  irritation  of  a  much  wider  area  may 
give  rise  to  the  same  phenomena.  Eckhard  has  shown  that  destruction  of 
the  vermis  cerebelli  in  rabbits  gives  rise  to  the  presence  of  sugar  in  the 
urine,  which  is  not  attended  by  any  alteration  in  the  blood  pressure,  and 
consequently  is  not  likely  to  be  caused  by  disturbances  in  the  circulation. 
Irritation  of  the  vermis  only  gives  rise  to  hydrtemia  when  the  vaso-motor 
nerves  of  the  liver  have  been  previously  divided.  The  opinion  of  Schifi"  is 
still  further  confirmed  by  the  fact  that  injuries  of  the  vaso-motor  con- 
ducting paths,  in  their  passage  downwards  from  the  medulla  oblongata 
through  the  cord,  are  followed  by  diabetes.  Diabetes  is  also  caused  by 
section  of  the  spinal  cord  anywhere  down  to  the  level  of  the  first  lumbar 
vertebra  (Schifi",  Eckhard),  by  destruction  of  the  upper  and  lower  cervical, 
and  of  the  upper  thoracic  sympathetic  gangha  (Eckhard,  Cyon),  or  even 
after  section  of  the  large  peripheral  nerve  trunks,  such  as  the  sciatic 
(Schifi").  If  the  pneumogastric  nerve  be  cut  in  the  neck,  stimulation  of 
the  upper  end  is  followed  by  dilatation  of  the  vessels  of  the  Uver,  and  the 
appearance  of  sugar  in  the  urine.  The  most  reasonable  supposition  in 
explanation  of  these  phenomena  is  that  vaso-motor  paralysis  of  the  hepatic 
artery  causes  dilatation  and  engorgement  of  the  hepatic  vessels,  giving  rise 
to  an  increased  production  of  sugar.  In  1868,  Braun  drew  attention  to  the 
frequent  presence  of  sugar  in  the  urine  in  cases  of  sciatica,  and  this  obser- 
vation has  since  been  confirmed  by  Rosenstein,  Evdenburg,  and  others. 

*  Schiff,    Journal  de  Tanatomie  et  de  la  physiologic.     Tome  III.,  1866,  p.  354. 


INDIVIDUAL  MOTOR  MECHANISMS.  22-5 

§  105.  Neurotic  Enlargement  of  the  Spleen  and  Liver. — 
Certain  forms  of  enlargement  of  the  spleen  and  liver  are  probably 
due  to  paralysis  of  the  vaso-motor  nerves  of  the  respective  organs. 
The  nerves  of  the  spleen  are  derived  from  the  semilunar  and 
splenic  plexuses,  and  these  are  now  proved  to  consist  both  of 
afferent  and  efferent  fibres.  Section  of  the  efferent  fibres  causes 
enlargement  of  the  spleen,  along  with  a  dark  blue  colour  of  its 
tissue,  while  irritation  of  these  fibres  causes  a  reduction  of  the 
size  of  the  organ,  its  tissue  becoming  of  a  grey  colour  from 
anaemia.  The  number  of  the  white  corpuscles  conveyed  from 
the  spleen  by  the  veins  is  diminished  in  both  cases,  but  the 
diminution  is  to  a  greater  degree  in  vaso-motor  paralysis. 
When,  therefore,  the  spleen  has  been  previously  swelled,  con- 
traction of  its  substance  leads  to  a  considerable  increase  of  the 
white  blood  corpuscles  in  the  veins.  The  centripetal  fibres  are 
according  to  Bulgak,  found  exclusively  in  the  greater  splanchnics, 
while  their  reflex  centre  is  found  in  the  cord  between  the  first 
and  fourth  cervical  vertebrse.  Strong  irritation  of  the  central 
ends  of  the  vagus^  and  sympathetic  in  the  neck  produces  reflex 
contraction  of  the  vessels  of  the  spleen,  but  this  appears  to  be  a 
consequence  of  commencing  asphyxia. 

How  far  enlargement  of  the  spleen  in  intermittent  fever  and 
other  malarious  diseases  and  in  leucocythsemia  is  dependent 
upon  vaso-motor  action  is  doubtful.  With  respect  to  the  liver, 
it  has  been  found  that  destruction  or  extirpation  of  the  coeliac 
and  mesenteric  plexuses  causes,  besides  other  phenomena,  con- 
gestion and  enlargement  of  the  organ.  The  liver  is  also  in- 
creased in  size  and  congested  in  cases  of  diabetes  mellitus, 
caused  by  paralysis  of  the  vaso-motor  nerves  of  the  liver  in 
their  cerebro -spinal  or  peripheral  course.  It  has  not  yet  been 
decided  how  far  many  other  kinds  of  enlargement  of  the  organ 
are  dependent  upon  vaso-motor  action,  but  it  is  at  least  very 
probable  that  the  congestion  which  takes  place  in  frequently 
repeated  attacks  of  migraine  is  of  this  nature. 

'  Tarchanoff .  "  Ueber  die  Innervation  der  Milz  und  deren  Beziehung  zur  Leuco- 
cythamie."    Pfliiger's  Aichiv.,  Bd.  VIII.,  1874,  p.  97. 


VOL.  I. 


226 


CHAPTER   VI. 


III.— TROPHONEUEOSES. 
(I.)— TROPHIC    AFFECTIONS    OF    THE    NERVOUS    SYSTEM. 

§  106.  Peripheral  Nerves. 

In  the  cerebro-spinal  or  spasmodic  paralyses,  as  well  as  in 
hysterical  and  many  forms  of  peripheral  paralyses,  the  affected 
nerves  do  not  for  a  long  time  undergo  any  histological  changes. 
When  the  paralysis  has  existed  for  many  years  the  nerve  under- 
goes slight  atrophy,  the  result  of  inactivity,  or  the  neurilemma 
may  undergo  a  moderate  degree  of  hypertrophy,  especially  when 
there  is  coincident  muscular  contracture. 

In  some  forms  of  the  spino-peripheral  or  atrophic  paralyses, 
such  as  progressive  muscular  atrophy,  the  interstitial  tissue  of  the 
nerves  becomes  somewhat  hypertrophied,  and  the  nerve  fibres 
undergo  progressive  atrophy. 

In  other  forms  of  atrophic  paralysis,  of  which  infantile  and 
traumatic  peripheral  paralysis  may  be  taken  as  the  type, 
remarkable  changes  occur  in  the  nerves — changes  which  have 
been  carefully  studied  by  means  of  experiments  on  animals. 
Nasse^  was  the  first  who  studied  those  which  occur  in  the 
peripheral  segment  of  a  divided  nerve ;  but  A.  Waller,^  as  will 
be  hereafter  seen,  made  the  most  important  discovery  with 
respect  to  the  influences  which  determine  nerve  degeneration. 

1  Nasse.  "  Ueber  die  Versenderungea  der  Nervenfasern  nach  ihrer  Durch- 
schnieduDg."    Miiller's  Archiv.,  1839,  p.  413, 

*  Waller  (A.).  MuUer's  Archiv.,  1852,  p.  392.  "  Nouvelle  me'thode  pour 
r^tude  du  systeme  nerveux  applicable  a  I'investigation  de  la  distribation  anatomique 
des  cordons  nerveux,  et  du  diagnostic  des  maladies  du  systeme  nerveux  pendant  la 
vie  et  apres  la  mort."  Comptes  Rendu,  Tome  XXaIII.,  1851,  p.  606.  "  Nouvelles 
recherches  sur  la  regeneration  des  fibres  nerveuses."  Comptes  Rendu,  Tome 
XXXIV.,  1852,  p.  675. 


TROPHONEUROSES.  227 

§  107.  Wallerian  Degeneration. — The  changes  undergone  by- 
nerves  after  section  have,  subsequently  to  the  time  of  Waller, 
been  studied  by  Schiff,^  Philippeaux  and  Vulpian,^  Neumann,^ 
Erb,*  Eichhorst,^  Leegaard,®  Dejerine,'  and  many  others,  but  the 
most  elaborate  account  of  these  changes  is  given  by  Ranvier,®  iu 
his  work  on  the  histology  of  the  nervous  system,  and  the 
following  summary  is  mainly  derived  from  that  work. 

The  earlier  changes  which  occur  after  section  of  a  nerve  are  Hmited  to 
the  peripheral  and  central  ends  of  the  divided  fibre,  and  do  not  usually 
extend,  in  either  direction,  beyond  the  first  node  of  Ranvier,  although  slight 
changes  may  occasionally  be  observed  as  far  as  the  second  node  from  the 
point  of  injury.  If  the  ends  of  the  divided  nerve  be  examined  a  few  hours 
after  section,  the  medullary  sheath  is  seen  to  be  swollen  and  opaque  ;  vv^hile 
the  interannular  nuclei  may  already  begin  to  manifest  traces  of  constric- 
tion prior  to  division.  Between  the  divided  ends  of  the  nerve  there  is  an 
accumulation  of  red  and  white  blood  corpuscles.  The  white  corpuscles  in 
the  course  of  a  few  days  form  knob-like  projections  at  each  end  of  the 
nerve,  which  soon  become  fused  where  the  loss  of  substance  in  the  nerve  has 
been  small.  The  white  corpuscles  after  a  time  increase  in  size,  become 
spindle-shaped,  and  ultimately  transformed  into  connective  tissue  fibres. 
The  divided  nerve  becomes  thus  soldered  together  by  means  of  connective 
tissue,  but  this  tissue  does  not  take  an  active  part  in  the  regeneration  of 
the  nerve  fibres  themselves. 

If,  however,  the  peripheral  end  of  the  nerve  undergoes  paralytic 
degeneration,  a  fresh  series  of  changes  occur,  these  taking  place  almost  s 
simultaneously  in  the  entire  length  of  the  peripheral  portion  of  the  fibre. 
"When  the  peripheral  portion  of  the  divided  nerve  is  examined  two  days 
after  section,  the  medulla  of  the  divided  fibres  is  foimd  coagulated,  opaque, 
granular,  and  broken  up  into  cyhndrical  masses.  The  condition  of  the 
peripheral  fibres  of  the  sciatic  nerve  of  a  hare  fifty  hours  after  section  is 
represented  in  Fig.  17,  1,  2.  The  nucleus  {n)  of  the  interannular  segment 
has  become  more  volimiinous  and  conta,ins  a  large  and  well  marked  nucleolus. 

^  Schiff.  "  Sur  la  regeneration  des  nerfs  et  sur  les  alterations  qui  surviennent 
dans  les  nerfs  paralyses."    Comptes  Rendu,  Tome  XXXVIII.,  1854,  p.  448. 

*  Philippeaux  and  Vulpian.  "Note  sur  des  experiences  demontrant  queries 
nerfs  separes  des  centres  nervenx  peuvent,  apres  s'&tre  alt^res  compietement,  se 
r^ggnerer  tout  en  demeurant  Isolds  de  ces  centres  et  recouvrer  leurs  propri^tes  phy- 
siologique."    Comptes  Rendu,  Tome  XLIX.,  1859,  p.  507. 

^  Neumann.  "  Degeneration  und  Regeneration  nach  Nervendurchschneidung." 
Arch.  f.  Hielk.,  Bd.  IX.,  1868. 

*  Erb.  Deutsches  Arch.  f.  klin.  Med,  Bd.  IV,,  1868,  p.  535 ;  and  Bd,  V,, 
1869,  p.  42. 

*  Eichhorst.  "  Ueher  Nervendegeneration  und  Nervenregeneration."  Vir- 
chow's  Archiv.,  Bd.  LIX.,  1874,  p.  1. 

"  Leegaard,    Deutsches  Arch,  f.  klin.  Med,    Bd.  XXVI.,  1880,  p.  459. 

'  Cossy  et  Dejerine,   Archives  de  physiol.  norm,  et  pathol.   Tome  II. ,  1875,  p,  567. 

*  Ranvier,    Lemons  sur  I'histologie  du  systeme  nerveux.    Paris,  1878. 


228 


TROPHONEUROSES. 
Fig.  17. 


Fig.  17  'after  Ranvier).  Alterations  in  Nerve  Fibres  after  Section. ~1  and  2.  Two 
nerve  fibres  from  the  peripheral  segment  of  the  sciatic  nerve  of  a  hare  fifty 
hours  after  section,  examined  after  maceration  for  twenty-four  hours  in  a 
solution  of  perosmic  acid ;  (n)  nucleus  of  interannular  segment,  swollen  and 


TROPHONEUROSES.  229 

The  protoplasm  which  surrounds  the  nucleus  becomes  so  abundant  and  well 
developed  at  the  level  of  the  nucleus,  that  it  fills  the  caUbre  of  the  nerve 
tube  and  completely  interrupts  the  medullary  sheath.  Accumulations  of 
protoplasm  also  take  place  at  other  points  of  the  interannular  segment,  and 
these  may  constrict,  more  or  less  deeply,  the  medullary  sheath,  or  may  even 
completely  interrupt  it.  The  protoplasm  becomes  filled  with  the  fine  fat 
granules  into  which  the  myeline  has  been  converted,  and  a  similar  granular 
debris  may  be  observed  outside  the  sheath  of  Schwann,  and  in  the  substance 
of  the  cells  of  the  endoneurium.  During  the  next  two  or  three  days  the 
segmentation  of  the  medullary  sheath  proceeds,  and  the  cyhndrical  masses 
become  broken  up  into  globular  masses  (Fig.  17,  5  and  6),  which  at  the  end 
of  the  first  week  after  section  are  converted  into  drops  of  variable  size, 
amongst  which  a  progressively  increasing  number  of  fine  fat  grantdes  may 
be  observed.  Dm-ing  this  period  the  altered  medulla  occupies  a  larger 
space  than  in  health,  so  that  the  fibres  appear  broader  than  usual,  although 
their  outline  is  somewhat  irregular  and  wavy.  But  as  the  change  advances 
the  medulla  becomes  gradually  converted  into  fat  granules,  which  are 
absorbed. 

It  has  been  asserted  by  Erb  and  other  authorities  that  the  axis  cylinder 


detached  from  the  sheath  of  Schwann;  (p)  mass  of  protoplasm,  in  which  fat 
granules  and  drops  of  myeline  {g  and  m  y)  may  be  observed.  The  medullary 
sheath  is  completely  interrupted  at  the  level  of  the  nucleus,  while  at  a  it  has 
undergone  strangulation. 

3.  Appearance  presented  by  the  peripheral  fibres  four  days  after  section  of 
the  sciatic  nerve  of  a  hare,  originally  hardened  in  a  solution  of  bichromate  of 
ammonia  and  stained  by  picrocarmine  ;  (c  ?/)  fragments  of  the  axis  cylinder 
retracted,  somewhat  tortuous  and  embedded  in  a  mass  of  myeline  (to  y) ; 
(p)  protoplasm  swollen  and  granular. 

4.  Fibre  same  as  3,  but  originally  coloured  by  picrocarmine  after  maceration 
in  perosmic  acid ;  (n)  nucleus  compressing  and  partially  interrupting  the  medul- 
lary sheath  and  the  axis  cylinder ;  p,  protoplasm. 

5  and  6.  Fibres  from  the  peripheric  portion  of  the  sciatic  nerve  of  a  pigeon 
three  days  after  section  (same  method  of  preparation  as  4).  5.  Median  portion 
of  an  interannular  segment  presenting  a  single  swollen  nucleus  (n)  surrounded 
by  a  mass  of  protoplasm  (p).  6.  Presents  four  nuclei  (n"  n"  n"  n")  in  a  single 
interannular  segment.  The  protoplasm  {p)  which  surrounds  them  is  not  seg- 
mented, but  contains  masses  of  myeline  in  its  interior. 

7.  Fibres  from  the  central  end  of  the  sciatic  nerve  of  a  hare  ninety  days 
after  section  (same  method  of  preparation  as  4).  Dark  upper  portion  repre- 
sents primitive  nerve  fibre  surrounded  by  the  sheath  of  Schwann  (s),  and 
terminating  by  a  knobby  enlargement  of  its  medullary  sheath  (6).  From  the 
extremity  of  this  termination  a  second  tube  (t/)  issues,  which  divides  and  sub- 
divides until  it  forms  a  bundle  of  very  fine  medullary  fibres  {F ),  surrounded  by 
a  secondary  sheath  (s')  emanating  from  the  sheath  of  Schwann ;  m,  drops  of 
myeline  derived  from  the  old  nerve  fibre. 

8.  A  large  nerve  fibre  of  the  central  extremity  of  the  pneumogastric  nerve 
of  a  hare  seventy-two  days  after  section — maceration  in  perosmic  acid.  The 
medullary  sheath  {t)  terminates  by  a  knobby  extremity  (6),  and  from  this  ex- 
tremity secondary  medullated  nerve  tubes  {f  t")  issue,  as  well  as  fibres  without 
myeline ;  (s)  the  sheath  of  Schwann  of  the  primary  fibre  forming  secondary 
nerve  sheath  (s')  for  the  nerve  fibres  which  issue  from  it. 

9.  A  nerve  tube  of  the  peripheric  segment  of  the  pneumogastric  of  a  hare 
six  days  after  section.  The  portions  a  a,  which  are  neither  occupied  by  drops 
of  myeline  nor  by  nuclei,  are  collapsed,  and  the  tube  is  contracted  at  this  level, 
V  n,  nuclei  of  the  interannular  segment,  having  undergone  proliferation ;  m  m, 
drops  of  myeline. 


230  TROPHONEUEOSES. 

persists  without  apparent  injury  long  after  the  medullary  sheath  has  disap- 
peared. Eanvier,  however,  afl&rms  that  the  protoplasm  collects  at  the  level 
of  the  interannular  nucleus  to  such  an  extent  that  after  having  pressed 
upon  and  absorbed  the  medullary  sheath  it  attacks  and  intersects  the  axis 
cylinder  {Fig.  17,  3,  p,  cy).  The  axis  cylinder  may  also  be  subsequently 
cut  across  by  the  accumulation  of  protoplasm  at  other  levels  than  that  of 
the  interannular  nucleus. 

Subsequently  to  the  fourth  day  after  section  a  new  phenomenon  may 
be  noticed.  The  nucleus  may  be  observed  situated  near  the  middle  of  an 
interanniilar  segment,  and  containing  a  very  large  and  distinct  nucleolus 
(Fig.  17,  5,  n).  The  nucleolus  may  first  be  seen  to  undergo  hour-glass 
contraction,  and  after  successive  changes  it  ends  by  dividing  into  two: 
After  a  time  the  nucleus  exhibits  similar  transformations,  and  ends  by 
becoming  completely  subdivided  into  two  nuclei,  each  of  which  may  sub- 
sequently imdergo  subdivision.  In  Fig.  17  (6,  n"  n"  n"  n"),  four  nuclei  are 
observed  to  correspond  to  one  interannular  segment.  A.t  a  later  period  of 
the  degenerative  process  the  greater  portion  of  the  medulla  is  absorbed, 
although  some  globular  masses  may  accumulate  at  certain  points  in  the  , 
length  of  the  fibre  {Fig.  17,  6,  m) ;  the  process  of  miiltiplication  of  nuclei 
ceases;  and  even  the  axis  cylinder  disappears  from  considerable  portions 
of  the  length  of  the  fibre.  The  result  of  this  process  is  that  the  sheath  of 
Schwann  is  completely  empty  of  contents  at  certain  points,  and  collapses 
so  that  the  degenerated  fibre  appears  exceedingly  slender  {Fig.  17,  9,  a  a). 
The  calibre  of  the  tube  is  distended  at  intervals  by  elongated  nuclei  arranged 
in  a  series  {Fig.  17,  9,  n  in),  by  fragments  of  the  axis  cylinder,  or  by  globular 
masses  of  altered  myeline  {Fig.  17,  9,  m))  so  that  the  degenerated  nerve 
tube  appears  as  a  delicate  pale  band  with  irregularly  undulating  contour. 

With  the  disappearance  of  the  medullary  sheath  the  degenerated  nerve 
loses  its  white  colour,  and  assumes  a  grey  appearance,  the  fibres  shrink, 
and  the  nerve  looks  small  and  wasted.  It  is  probable  that  this  process  is 
accompanied  by  proliferation  of  the  cells  of  the  endoneurium  and  even  of 
the  perineiu-ium ;  a  process  which  is  followed,  in  long-standing  cases,  by 
cicatricial  shrinking  or  cirrhosis,  rendering  denser  the  textiue  of  the 
degenerated  nerve,  but  adding  still  further  to  its  atrophied  appearance, 

§  108.  Regeneration  of  Kerves. 

The  process  of  regeneration  difiers  greatly  according  as  the  nerve  has 
been  simply  divided  by  a  sharp  knife  or  a  portion  has  been  excised.  In 
both  cases  the  portion  above  the  point  of  division  remains  normal,  with 
the  exception  of  the  changes  which  occur  in  the  medullary  sheath  as  far  as 
the  first  node  of  Eanvier.  If  the  ends  of  the  divided  nerve  are  maintained 
in  apposition  during  the  reparative  process,  it  is  probable  that  the  axis 
cyHnders  of  the  central  may  become  united  with  those  of  the  peripheral 
end  before  any  serious  degenerative  changes  have  occurred  in  the  latter, 
and  that  in  this  manner  "  union  by  first  intention  "  is  obtained.     The  case 


TROPHONEUROSES,  231 

is,  however,  different  when  the  ends  of  the  nerve  are  not  maintained  in 
apposition,  and  when  a  portion  has  been  excised.  Waller,  who  was  the 
first  to  draw  attention  to  the  importance  of  this  subject,  thought  that 
the  nerve  tubes  of  the  peripheral  segment  degenerated  in  their  entire 
extent,  and  that  the  regenerative  process  was  due  to  an  active  growth  of 
the  nerve  tubes  of  the  central  segment.  Remak^  subsequently  described 
the  formation  of  new  nerve  fibres  in  the  interior  of  the  degenerated  nerve 
tubes  of  the  peripheral  segment.  The  dehcate  investigations  of  Ranvier 
have,  however,  shown  that  the  axis  cylinder  is  completely  destroyed  in 
the  peripheric  segment,  and  that  the  active  growth  of  new  fibres  proceeds 
from  the  nerve  tubes  of  the  central  segment.  Ranvier  describes  several 
ways  in  which  the  central  ends  give  rise  to  new  nerve  fibres ;  but  it  must 
suffice  to  mention  here  one  or  two  of  the  more  common  of  them.  The 
central  tube  terminates  by  a  slight  enlargement  at  one  of  the  nodes  {Fig. 
17,  7),  and  from  this  extremity  a  nerve  tube  {b')  issues,  which,  although 
thin,  is  characterised  by  a  medullary  sheath  (s')  and  interannular  nucleus. 
This  tube  soon  subdivides  into  two  others  of  almost  the  same  size  as  itself, 
and  each  of  these  in  their  turn  subdivides  into  two  new  nerve  tubes,  so 
that  the  old  sheath  of  Schwann  becomes  distended  by  a  bundle  of  new 
fibres  {Fig.  17,  7,  F).  Rounded  masses  of  altered  myeline  (m)  are  often 
observed  at  intervals  to  lie  between  the  old  sheath  and  the  young  fibres. 

At  other  times  several  nerve  tubes  {Fig.  17,  8,  f  t'  t"),  some  of  them 
possessing  distinct  medullary  sheaths,  while  others  consist  of  naked  axis 
cylinders,  issue  from  the  extremity  of  the  central  fibre,  and  these  also  ex- 
tend towards  the  periphery.  These  new  fibres  on  reaching  the  peripheral 
segment  penetrate  for  the  most  part  into  the  interior  of  the  degenerated 
tubes;  but  some  of  them,  according  to  Ranvier,  insinuate  themselves 
between  the  old  sheath  and  the  substance  of  the  endoneurium.  It  would 
appear,  therefore,  that  Waller's  original  opinion  with  respect  to  the  centri- 
fugal development  of  the  new  nerve  tubes  from  the  tubes  which  are  still 
connected  with  the  ganglion  cells  of  the  anterior  horns  is  confirmed  by  the 
elaborate  researches  of  Ranvier,  whatever  may  be  the  details  of  the  suc- 
cessive steps  by  which  the  union  is  effected.  It  is  right,  however,  to  state 
that  Leegaard  has  found  partially  regenerated  fibres  in  the  old  sheaths  of 
Schwann  of  the  peripheral  portion  of  the  divided  nerve  in  the  absence  of 
any  connection  having  been  formed  with  the  central  end  of  the  nerve.  The 
duration  of  the  process  of  regeneration  varies  according  as  there  is  simple 
division  of  the  nerve  or  a  portion  is  resected.  It  is  also  affected  by 
numerous  other  circumstances,  the  most  important  of  which  is  the  length 
of  the  peripheral  part  of  the  divided  nerve,  restoration  being,  according  to 
Leegaard,^  so  much  the  slower  the  longer  that  portion  of  the  nerve  is;  as, 
indeed,  might  be  expected  to  be  the  case  if  regeneration  takes  place  from 
the  central  end  outwards,     Schiff"  found  complete  reunion  of  divided  nerves 

'  Remak.    "  Ueber  die  Wiedererzeugung  von  Nervenfasern."   Virchow's  Archiv. , 
Bd.  XXIII.,  1862,  p.  441. 

*  Leegaard.     Deutsches  Arch.  f.  klin.  Med.    Bd.  XXVI.,  1880,  p.  516. 


232  TROPHONEUROSES, 

in  young  animals  in  from  seven  to  fourteen  days,  and  Paget  found  clinically 
in  two  cases  traces  of  returning  sensibility  in  fifteen  days.  After  division 
of  the  facial  nerve  paralysis  of  the  facial  muscles  usually  diminishes  only 
after  two  or  three  months.  Sensory  functions  are  restored  considerably 
sooner  than  motor  functions.  If  the  portion  of  nerve  destroyed  or  resected 
exceeds  a  certain  length  regeneration  will  not  take  place.  Regeneration  is 
not  hkely  to  take  place  when  the  length  of  lost  nerve  exceeds  two  inches, 
but  Weir  Mitchell  states  that  in  man  there  are  instances  of  at  least  three 
having  been  restored. 

§  109.  Dege7ieration  of  the  Conducting  Paths  of  the  Spinal 
Cord  and  Brain. — It  has  been  found  that,  when  the  conducting 
paths  of  the  spinal  cord  and  brain  are  interrupted  in  any  part 
of  their  course,  the  fibres  on  one  side  of  the  lesion  undergo 
degeneration  until  their  termination  in  grey  substance.  It  is 
evident,  therefore,  that  their  degeneration  is  only  of  much 
importance  when  the  fibres  of  the  conducting  path  possess  con- 
siderable length.  When  the  fibres  are,  after  a  short  course, 
interrupted  by  cells,  the  degeneration  which  follows  injury  will 
be  limited  to  the  immediate  neighbourhood  of  the  lesion ;  but 
when  the  fibres  pursue  a  long  course  uninterrupted  by  grey 
matter,  the  degeneration  may  extend  for  a  long  distance  beyond 
the  seat  of  injury. 

It  is  imnecessary  to  describe  in  detail  the  process  of  degeneration  as  it 
occurs  in  the  fibres  of  the  central  conducting  paths,  inasmuch  as  it  is  in  aU 
essential  particulars  similar  to  that  which  occurs  in  the  peripheral  segments 
of  divided  nerves.  About  three  weeks  after  the  injury  the  fibres  of  the 
conducting  path  become  degenerated  in  their  entire  length,  the  con- 
ducting path  itself  assumes  a  grey  or  yellowish  grey  colour,  and  becomes 
somewhat  denser  than  the  surrounding  healthy  white  substance,  hence  the 
process  is  called  sclerosis}  It  has  also  been  observed  that  the  fibres  of 
some  of  the  conducting  paths  of  the  encej)halo-spinal  system  undergo 
degeneration  or  sclerosis  above  the  seat  of  the  lesion,  while  others  degenerate 
below  the  seat  of  lesion.  If  the  continuity  of  the  spinal  cord,  for  instance, 
be  interrupted,  say,  in  the  upper  dorsal  region,  by  the  pressure  of  a  tiunour, 
or  by  Potts'  disease  of  the  vertebral  column,  and  death  supervene  a  few 
weeks  afterwards,  the  columns  of  GoU  {Fig.  3,  g)  degenerate  above  the  seat 
of  the  lesion  as  far  as  the  clavate  nucleus  {Fig.  3,  c  n)  and  the  direct  cere- 
bellar fibres  {Fig.  3,  d  c),  probably  until  their  termination  in  the  grey  cortex 

'  Tiirck.  "Ueber  ein  bislier  unbekanntes  "Verhalten  des  Riickeninarkes  bei 
Hemiplegie."  Ztschr.  d.  ges.  d.  Aerzte  zu  Wien,  1850,  p.  6.  See  also  Earth. 
"Ueber  secondare  Degeneration  des  Riickenmarks."  Arch.  f.  Heilkunde,  1869, 
X  ,  p.  433;  and  Bouchard.  "Des  degeneration  secondaires  de  la  moelle  epin." 
Arch,  gener.  de  m^d.,  Tome  I.,  1866,  pp.  272,  441,  561. 


TROPHONEUROSES.  233 

of  the  cerebellum,  although  the  degeneration  has  not  been  actually  traced 
beyond  the  upper  end  of  the  medulla  oblongata.  The  fibres  of  the  pyra- 
midal tract  {Fig.  4,  P,  T,  and  Fig.  2,  5  5  M),  on  the  other  hand,  imdergo 
degeneration  below  the  seat  of  the  lesion  down  to  their  terminations  in  the 
grey  anterior  cornu.  If  the  fibres  of  the  pyramidal  tract  be  injured  either 
in  the  spinal  cord,  medulla  oblongata,  pons,  middle  third  of  the  crusta 
(Fig.  5,  P',  P),  middle  third  of  the  posterior  segment  of  the  internal  capsule, 
corona  radiata,  or  where  they  join  the  cortex  of  the  brain,  the  fibres  below 
the  seat  of  injury  undergo  degeneration  down  to  their  termination  in  the 
grey  anterior  cornu  of  the  spinal  cord.  Briefly  expressed,  it  is  said  that  the 
columns  of  GoU  and  the  direct  cerebellar  tract  undergo  ascending  sclerosis, 
while  the  pyramidal  tract  undergoes  descending  sclerosis. 

§  110.  Theory  of  Nerve  Degeneration. — Waller  was  the  first 
to  observe  that  when  a  mixed  nerve  is  divided  the  peripheral 
portion  degenerates  throughout  its  whole  course  in  a  few  weeks, 
while  the  portion  attached  to  the  cord  does  not  degenerate.  He 
found,  however,  that  when  the  posterior  or  afferent  root  of  the 
nerve  is  cut  between  its  ganglion  and  the  cord,  the  peripheral 
portions  attached  to  the  ganglion  do  not  degenerate,  but  the 
small  portion  attached  to  the  cord  soon  wastes.  He  therefore 
concluded  that  the  efferent  fibres  receive  their  nutritive  in- 
fluence from  the  caudate  cells  of  the  anterior  horns,  and  the 
afferent  fibres  from  the  ganglia  of  the  posterior  roots,  and 
formulated  the  general  law  that  nerve  fibres  degenerate  when 
they  are  separated  from  their  trophic  centres.  With  respect  to 
the  central  conducting  paths  it  appears  certain  that  the  degene- 
ration occurs  along  the  line  of  the  conduction  of  the  fibres.  The 
columns  of  Goll  and  the  direct  cerebellar  tract,  which  undergo 
ascending  sclerosis,  are  centripetal,  and  the  pyramidal  tracts, 
which  undergo  descending  sclerosis,  are  centrifugal  conducting 
paths.  It  would  appear  that  the  large  caudate  cells  found  in  the 
inner  division  of  the  third  layer  of  the  cortex  of  the  brain  in 
the  psycho-motor  centres,  and  which  are  almost  in  every  respect 
similar  to  the  caudate  ganglion  cells  of  the  anterior  cornua  of 
the  cord,  form  the  trophic  centres  for  the  fibres  of  the  pyramidal 
tract ;  but  whether  the  cells  of  the  ganglia  of  the  posterior  roots, 
those  of  the  posterior  grey  horns,  or  of  the  vesicular  column  of 
Clarke  form  the  trophic  centres  of  the  fibres  of  the  columns  of 
Goll,  and  of  the  cerebellar  tracts,  is  unknown. 

It  becomes  interesting  to  know  why  simple  separation  of  a 


234  TROPHONEUROSES. 

nerve  fibre  from  its  trophic  centre  should  produce  the  changes 
which  have  just  been  described.  These  changes,  broadly  ex- 
pressed, consist  in  the  progressive  destruction  of  the  special 
elements  of  the  nerve  fibre — the  medullary  sheath  and  the  axis 
cylinder — along  with  increased  nutritive  activity  of  the  general 
structures — the  nucleus  and  protoplasm.  The  process  of  develop- 
ment, both  with  respect  to  structure  and  function,  is  always 
characterised  by  the  subordination  of  the  general  to  the  special, 
while  the  process  of  degeneration  manifests  a  reverse  tendency  of 
subordinating  the  special  to  the  general.  The  special  structures 
of  the  nerve  fibre,  the  medullary  sheath,  and  axis  cylinder  could 
never  have  been  developed  unless  the  general  functions  of  the 
nucleus  and  protoplasm  had  been  kept  to  some  extent  in  check 
by  some  force,  and  this  check  may  be  supposed  to  be  exercised 
by  a  trophic  centre.  When  once  the  moderating  or  inhibitory 
influence  of  the  trophic  centre  is  removed,  the  special  structures 
lose  in  the  struggle  for  existence,  while  the  general  functions  of 
the  nucleus  and  protoplasm  become  more  active  and  prominent. 
It  is  not  necessary,  therefore,  to  suppose  that  the  multiplication 
of  the  nuclei  and  the  great  increase  in  the  amount  of  proto- 
plasm present  during  the  degenerative  process  is  the  result  of 
irritation ;  and  if  multiplication  of  nuclei  in  this  instance  be  not 
a  test  of  previous  irritation,  it  is  not  a  trustworthy  test  of  irrita- 
tion at  other  times.  The  multiplication  of  the  nuclei  of  mus- 
cular fibres,  for  instance,  which  takes  place  during  degenerative 
processes  is  no  more  a  sign  of  previous  irritation  than  a  similar 
multiplication  in  the  case  of  degeneration  of  nerve  fibres. 

(II.)— MUSCULAR  TROPHONEUROSES. 

In  order  to  gain  a  better  insight  into  the  nutritive  changes 
which  muscles  suffer  in  connection  with  certain  diseases  of  the 
nervous  system,  it  is  necessary  to  mention  briefly  the  leading 
characteristics  of  their  healthy  structure. 

§  111.  Structure  of  Healthy  Muscle. 

1.  UnstriaUd  Muscles. — The  elements  of  unstriped  muscle  are  elongated, 
spindle-shaped  cells  of  variable  length,  each  containing  an  oblong  nucleus 
{Fiij.  18,  10).    Each  muscle  cell  consists  of  the  following  parts  (Klein)^ : 

>  Atlas  of  Histology,  by  E,  Klein  and  E.  Noble  Smith.     London,  ISSO.    p.  75. 


TROPHONEUROSES.  235 

(a)  a  fine  sheath  possessing  transverse  linear  thickenings  ;  (6)  a  central 
bundle  of  fibrils,  representing  the  contractile  substance  or  core ;  (c)  an 
oblong  nucleus,  including  a  fine  network  which  anastomoses  at  the  poles  of 
the  nucleus  with  the  bundle  of  fibrils  of  the  core.  The  muscle  cells  are 
aggregated  to  form  a  bundle,  the  cells  being  held  together  by  a  cement 
substance  in  which  flattened  connective  tissue  cells,  and  occasionally  a  few 
connective  tissue  fibres,  may  be  observed,  which  represent  the  endomysium. 
The  individual  bundles  are  in  their  turn  aggregated  to  form  larger  bundles, 
by  means  of  fibrous  connective  tissue  of  the  ordinary  description,  consti- 
tuting the  perimysium.  The  endomysium  and  perimysium  correspond 
respectively  with  the  endoneurium  and  perineurium  of  nerves. 

2.  Striped  Muscles  consist  of  long  cylindrical  fibres  aggregated  so  as  to 
form  bundles,  these  again  being  grouped  into  larger  fasciculi.  The  bundles 
are  surrounded  and  separated  by  ordinary  fibrous  connective  tissue,  consti- 
tuting the  perimysium.  From  the  latter  minute  bundles  of  connective 
tissue,  with  connective  tissue  cell  plates,  pass  between  the  individual  muscle 
fibres  to  form  the  endomysium. 

When  a  muscular  fibre  is  examined  along  its  longitudinal  axis  it  shows 
(a)  transverse  broad  thin  bands  of  a  highly  refractive  substance  {Fig.  18,  4,  h), 
and  (6)  narrow  bright  bands  of  a  less  refractive  substance  {Fig.  18,  4,  d). 
The  dim  band  alone  constitutes  the  contractile  portion  of  the  fibre,  and  it 
may  therefore  be  called  the  contractile  disc ;  while  the  bright  band  represents 
interstitial  substance,  and  may  be  called  the  interstitial  disc.  The  contractile 
disc  is,  however,  not  a  simple,  but  a  very  compound  body.  The  disc  is 
composed  of  sarcous  elements,  each  of  which  consists  of  a  prismatic  corpuscle. 
These  prismatic  corjiuscles  are  arranged  side  by  side,  so  that  when  the  con- 
tractile disc  is  examined  in  transverse  section  they  are  viewed  end  wise  and 
present  polygonal  surfaces  (Cohnheim's  fields.  Fig.  18,  2,  c).  The  sarcous 
elements  shrink  after  death  and  under  the  action  of  various  reagents,  and 
they  then  appear  to  be  embedded  in  or  surrounded  by  an  interstitial 
substance,  having  the  same  chemical  and  physical  characteristics  as  the 
interstitial  discs.  But  the  musciilar  fibre  can  be  analysed  longitudinally  as 
well  as  transversely.  The  fibre  can  be  separated  into  fibrillse  {Fig.  18,  3 
and  1  F),  which  consist  of  several  sarcous  element  prisms,  placed  end  on 
end,  and  held  together  by  a  prism  of  the  bright  substance  of  the  interstitial 
disc.  In  addition  to  the  fibrillse,  nuclei  {Fig.  18,  1  K,  2  K),  or  muscle 
corpuscles,  may  be  observed  scattered  at  intervals  in  the  length  of  the  fibre  ; 
these  representing  the  cells  from  which  the  fibre  was  originally  developed. 

These  different  elements — contractile  and  interstitial  discs,  primitive 
fibrillte,  and  nuclei — are  held  together  so  as  to  form  a  fibre  by  some 
important  structures. 

The  first  of  these  consists  of  a  transparent,  structiu-eless,  elastic  sheath, 
which  surrounds  the  contents  of  the  muscle  fibre  like  a  cuticle,  and  is  called 
the  Sarcolemma  (Fig.  18, 1,  s).  This  sheath  corresponds  to  the  neurilemma 
of  a  nerve  fibre.  Thin  elastic  membranous  septa  pass  transversely  through 
the  muscular  fibre  at  regular  intervals,  dividing  it  into  cylindrical  compart- 


236 


TROPHONEUROSES. 

Fig.  18. 


Tig.  18.  Structure  of  Muscle  (from  Landois'  "  Physiologic "). — 1,  Schema  of  the 
different  parts  of  a  Striated  Muscular  Fibre ;  S,  Sarcolemma ;  Q,  Transverse 
Striation  ;  F,  Fibdllse.  the  presence  of  which  give  rise  to  the  Longitudinal 
Striation  ;  K,  Nuclei  of  Muscular  Fibre  ;  N,  Termination  of  the  Motor  Nerve, 
showing  (a)  the  Axis  Cylinder,  which  terminates  in  Kiihne's  motor  end-plate. 
The  latter  is  viewed  in  profile,  and  rests  on  a  layer  of  nucleated  protoplasm.  2, 
Schema  of  a  portion  of  a  Transverse  Section  of  a  Nerve  Fibre,  showing  c,  Cohn- 
heim's  fields,  and  K,  Nucleus  lying  under  the  Sarcolemma.  3,  Isolated  Fibrillse 
from  a  Striated  Muscular  Fibre.  4,  Portion  of  a  Fibrilla  of  the  Muscle  of  an 
Insect  (greatly  magnified);  a,  Krause's  Lines  or  Membranes  which  limit  the  mus- 
cular compartments  ;  6,  the  dark  Doubly  Refractive  Substance ;  c,  Hensen's 
Lines  ;  d,  the  Singly  Refractive  Substance.  5,  Striated  Muscular  Fibre  break- 
ing up  into  Transverse  Discs.  6,  Striated  Muscular  Fibre-ceUs  from  the  Heart 
of  the  Frog.  7,  Structure  of  a  Muscular  Fibre  from  a  Human  Embryo  of  three 
months.  8,  Longitudinal  Section  of  the  Muscle  of  the  Heart.  9,  Transverse 
Section  of  the  Muscle  of  the  Heart ;  c,  Capillaries ;  6,  Connective  Tissue  Cor- 
puscles. 10,  Unstriped  Muscular  Fibres.  11,  Transverse  Section  of  Unstriped 
Muscular  Fibres.  12,  Striated  Muscular  Fibre  uniting  with  its  Tendon,  S.  13, 
Interfibrillary  Muscular  Nerve  Fibres  in  Striated  Muscle  (after  Gerlach). 


TROPHONEUROSES.  237 

ments — the  muscle-compartments  of  Krause.  Each  of  these  septa  passes 
through  the  centre  of  an  interstitial  disc  (Fig.  18,  4  a),  so  that  each  com- 
partment holds  the  contractile  disc  in  its  centre,  and  a  thin  interstitial 
disc  at  each  end.  According  to  Hensen  a  thin  transparent  "  median  disc" 
(Fiff.  18,  4  c)  divides  the  contractile  disc  into  two,  and  this  occupies  the 
centre  of  the  cylindrical  compartment ;  but  this  appearance  is  found  only 
under  exceptional  conditions  (Klein). 

Development  of  Muscular  Fibre. — Elongated  spindle-shaped  cells  are 
transformed  into  striped  muscle  fibres  at  an  early  period  of  embryonic  life. 
The  spindle-shaped  cells  increase  in  size,  their  nuclei  undergo  repeated 
division,  and  the  cell  substance,  beginning  from  the  periphery,  becomes 
differentiated  into  sarcous  elements  and  interstitial  substance  {Fig.  18,  7). 
What  remains  of  the  original  protoplasm  around  the  nuclei  represents  a 
muscle  corpuscle. 

Termination  of  Nerves  in  Striped  Muscle  Fibres. — Small  nerve  bundles 
situated  in  the  connective  tissue  of  the  perimysium  form  a  plexus  around 
the  muscular  bundles,  called  the  ground  plexus  (Klein).  Small  groups  of 
nerve  fibres  come  off  from  this  plexus,  and  pass  into  the  substance  of  the 
muscular  bundles.  They  also  form  a  plexus  in  the  substance  of  the  endo- 
mysium,  called  the  xntermediary  plexus.  From  the  intermediate  plexus 
isolated  meduUated  nerve  fibres  {Fig.  18,  1  «)  enter  the  individual  muscle 
fibres  in  an  oblique  or  vertical  manner,  the  sheath  of  Schwann  of  the  nerve 
fibre  becoming  fused  with  the  sarcolemma,  while  the  axis  cylinder  {Fig.  18, 
1  a),  having  lost  its  medullary  sheath,  passes  within  the  sarcolemma.  The 
axis  cylinder  branches  into  several  thin  fibres,  which  form  a  network  with 
one  another  {Fig.  18,  13)  between  the  fibrillse  but  near  the  surface  of  the 
fibre.  These  fibres  lie  embedded  in  a  granular,  plate-like  mass,  containing 
numerous  oval  nuclei,  and  termed  the  nerve  end-plate  of  Kiihne. 

§  112.  Histological  Changes  in  Paralysed  Muscles. — The 
histological  changes  which  occur  in  paralysed  muscles  vary 
greatly  according  to  the  nature  of  the  paralysis.  Paralysis 
resulting  from  disease  of  the  cortex  of  the  brain,  or  of  the 
centrifugal  conducting  paths  which  connect  it  with  the  spinal 
cord,  is  not  followed  by  active  atrophy  of  the  paralysed  muscles, 
unless,  indeed,  the  motor  ganglion  cells  of  the  central  grey  tube 
become  secondarily  implicated  in  the  disease.  When  simple 
voluntary  paralysis  has  existed  for  many  years,  the  fibres  of  the 
paralysed  muscles  atrophy  to  some  extent,  owing  to  their  long 
inactivity.  This  is,  however,  very  different  from  the  active 
atrophy  which  occurs  when  the  motor  ganglion  cells  of  the 
central  grey  tube,  or  the  efferent  fibres  which  connect  these 
with  the  muscles,  are  injured  or  diseased.     Neurotic  muscular 


238 


TROPHONEUROSES. 


atrophy  may  be  subdivided  for  practical  purposes  into  the 
following  stages  : — 1,  Simple  atrophy ;  2,  Atrophy  with  nuclear 
proliferation  ;  3,  Cirrhosis  of  muscle. 

(1)  Simple  Atrophy. — Less  is  known  with  regard  to  the  microscopical 
appearances  of  the  muscles  during  the  first  stage  of  the  disease  than  in  the 
later  stages.  In  simple  atrophy  and  the  early  stages  of  the  other  forms  of 
atrophy,  the  muscular  fibres  undergo  a  simple  diminution  in  size,  without 
any  degenerative  changes.  A  microscopical  examination  reveals  a  great 
number  of  fibres  of  small  diameter,  which  preserve  their  normal  striation, 
and  present  no  trace  of  fatty  degeneration.  Both  the  longitudinal  and 
transverse  striation  are  at  times  as  well  preserved  as  in  health  {Fig.  19,  a). 
It  would  appear  that  there  is  a  diminution  of  the  number  of  fibrillee  of 
which  the  fibre  consists ;  while  the  fibrillee  which  remain  do  not  seem  to 
be  sensibly  diminished  in  size.  At  other  times  the  striation  becomes  more 
delicate  and  less  marked  than  in  health,  probably  owing  to  a  diminution  in 
the  length  of  the  sarcous  elements  of  the  contractile  discs  (Fig.  19,  b).  The 
substance  of  the  contractile  discs  may  also  present  a  finely  graniilar  aspect, 
which  appears  to  be  the  first  indication  of  the  more  profound  chemical 
change  which  this  substance  subsequently  undergoes.  Even  at  a  very  early 
period  of  the  atrophy  indications  of  proliferation  of  the  muscle  corpuscles 
and  of  the  nuclei  of  the  endomysium  may  be  observed  ;^  but  these  appear- 
ances will  be  best  described  along  with  the  second  stage  of  the  process.     If 

Fig.  19. 


Fig.  19  (after  Hayem'').  Atrophy  of  Aluscular  Fibres  from  a  Case  of  Infantile 
Paralysis. — a,  Fibres  of  normal  size,  showing  multiplication  of  nuclei;  6,  simple 
atrophy,  with  granular  degeneration ;  c,  advanced  granular  degeneration,  with 
atrophy. 

'  Erb  (W.).  "  Pathologie  und  pathologische  Anatomie  peripherischer  Paralysen." 
Deutsches  Arch.  f.  klin.  Med.,  Bd.  V.,  1869,  p.  76. 

^  Hayem  (Georges).  Eecherches  sur  I'anatomie  pathologique  dea  atrophies 
muscularies.    Paris,  1873. 


TROPHONEUROSES. 


239 


the  connection  between  the  muscle  and  the  gangUon  cells  of  the  anterior 
grey  horns  of  the  spinal  cord  be  now  restored,  the  atrophied  muscular  fibres 
gradually  resume  their  normal  size  and  complete  restoration  takes  i^lace. 

(2)  A  trophy  with  Nuclear  Proliferation. — When  the  muscles  are  examined 
from  three  to  five  weeks  after  the  occurrence  of  the  injury,  it  is  found  that, 
in  addition  to  the  changes  already  described  as  occmring  during  the  first 
period,  the  contents  of  the  muscular  fibres  have  undergone  a  profotmd 
degeneration.  The  finely  granular  appearance  of  the  contents  of  the  fibre, 
which  was  mentioned  as  being  with  difficulty  observed  during  the  earliest 
stage,  now  becomes  a  characteristic  featm-e  of  the  process  (Fi(/.  19,  c).  The 
granules  at  first  probably  consist  of  altered  protein,  and  are  soluble  in  acetic 
acid  and  insoluble  in  ether ;  but  they  soon  become  distinctly  fatty,  being 
insoluble  in  acetic  acid  and  soluble  in  ether.  The  primitive  fibrils  now 
disappear,  and  only  small  fragments  of  the  fibres  present  here  and  there 
either  transverse  or  longitudinal  striation.  But  the  most  remarkable  change 
which  occurs  in  this  stage  of  muscular  atrophy  consists  of  proliferation  of 
the  nuclei  or  of  the  muscle  corpuscles.     At  first  the  corpuscles  are  observed 

Fig.  20. 


Fig.  20  (after  Hayem).  Infantile  Paralysis.— a  a,  Excess  of  connective  tissue,  con- 
taining a  large  number  of  connective  tissue  and  fat  cells ;  b  b,  atrophied  mus- 
cular fibres,  containing  a  large  number  of  nuclei ;  c,  simple  atrophy  of 
muscular  fibre. 


240  TROPHONEUROSES. 

to  be  more  numerous  than  in  healthy  fibres,  but  in  the  later  stages  of  the 
process  the  sarcolemma  may  become  almost  filled  with  masses  of  nuclei 
surrounded  by  granular  and  fatty  detritus,  while  the  contents  of  the  fibre 
are  completely  disintegrated  {Fig.  20,  b,  h).  During  the  time  in  which  the 
muscular  fibre  is  becoming  thus  altered  the  nuclei  of  the  endomysium  also 
proliferate,  so  that  a  much  larger  number  of  those  may  be  observed  lying 
between  the  atrophied  muscular  fibres  than  between  healthy  fibres ;  and  it 
is  to  the  subsequent  changes  which  these  connective  tissue  corpuscles 
undergo  that  the  third  stage  of  atrophy  is  mainly  due. 

(3)  Cirrhosis  of  Muscle. — The  connective  tissue  corpuscles,  now  greatly 
increased  in  number,  elongate  into  fibres  which  form  narrow  bands  of 
fibrous  tissue  running  parallel  to  the  direction  of  the  muscular  fibres,  and 
cicatricial  contraction  of  which  gives  rise  to  organic  shortening  of  the  muscle, 
or  rather  of  the  fibrous  tissue,  which  has  now  replaced  the  muscular  tissue. 
When  this  condition  has  been  reached  the  muscular  fibres  become  destoyed, 
and  restitution  of  the  muscle  is  impossible.  The  bands  of  fibrous  tissue 
which  result  from  the  development  into  fibres  of  the  cells  of  the  endomy- 
sium, and,  indeed,  it  might  be  added  of  the  cells  of  the  perimysium,  for  the 
process  extends  to  them,  contain  many  oat-shaped  nuclei  and  connective 
tissue  cells  {Fig.  20,  a,  a).  The  cells  not  unfrequently  become  distended 
with  fat,  and  the  deposit  of  fat  in  the  interstitial  tissue  may  be  so  abundant 
that  the  original  volume  of  the  muscle  may  be  maintained  or  even  exceeded. 

These,  then,  are  the  outlines  of  the  leading  features  presented  by  the 
different  degrees  of  neiu-otic  muscular  atrophy,  although  the  process  varies 
considerably  under  difierent  circumstances.  Vulpian^  thinks  that  a  more 
profound  alteration  of  muscle  occurs  after  section  or  excision,  than  any 
other  injury  of  a  nerve,  such  as  that  caused  by  contusion,  excision,  ligature, 
or  cauterisation.  The  modifications  in  the  degenerative  process  observed 
in  different  diseases  will  be  described  in  the  special  part  of  this  work.  It 
must  suffice  at  present  to  point  out,  that  the  first  stage,  or  simple  atrophy, 
is  met  with  in  those  cases  in  which  the  paralysed  muscles  exhibit  the  first 
degree  of  the  reaction  of  degeneration  ;  the  second  stage,  or  atrophy  with 
muscular  proliferation,  where  the  muscles  exhibit  the  second  degree  of  this 
reaction  ;  and  the  third  stage,  or  cirrhosis  of  the  muscle,  where  the  affected 
muscles  exhibit  the  third  degree  of  the  reaction  of  degeneration.  Electrical 
examination  will  therefore  enable  us  to  determine  the  degree  of  rduscular 
degeneration  which  has  been  reached,  and  consequently  to  foretell  whether 
the  patient  will  make  a  speedy  recovery,  or  a  slow,  tedious,  and  imperfect 
one,  or  whether  the  paralysis  is  completely  incurable. 

.  §  113.  Theory  of  Muscular  Atrophy. — It  is  now  fully  ascer- 
tained that  active  neurotic  atrophy  of  muscular  fibres,  with  rapid 
loss  of  faradic  contractility  of  the  affected  muscles,  never  occurs 

'  Vulpian.     "  Influence  des  lesions  des  nerfs  sur  les  muscles."     Archives  de 
physioL,  Tome  IV.,  1871-2,  p.  757. 


TROPHONEUKOSES.  241 

except  when  the  spinal  motor  mechanism  is  injured,  either  by 
disease  of  the  ganglion  cells  of  the  anterior  horns  of  the  spinal 
cord  and  the  corresponding  cells  in  the  medulla  oblongata,  or  of 
the  efferent  fibres  which  connect  these  with  the  muscles.  Active 
neurotic  atrophy  is  found  associated  with  acute  diseases  of  the 
grey  substance  of  the  cord,  as  acute  central  myelitis,  spinal 
apoplexy,  fractures  and  luxations  of  the  vertebral  column,  infantile 
spinal  paralysis  and  related  diseases.  It  occurs  also  in  connection 
with  diseases  of  the  efferent  fibres,  either  in  their  course  through 
the  anterior  columns  or  at  their  origin  in  the  anterior  roots  {Fig. 
13,  a  a),  or  in  their  course  to  the  muscles  through  the  peripheral 
nerves. 

The  question  now  arises  as  to  the  nature  of  the  injury  from 
which  active  atrophy  results.  It  was  first  stated  by  Brown- 
Sequard^  that  nerve-irritation  alone  is  capable  of  determining 
that  rapid  and  early  atrophy  of  the  muscles,  which  is  accompanied 
by  decrease  or  disappearance  of  faradic  contractility;  and  that 
simple  section  of  a  nerve  does  not  induce  atrophy  and  loss  of 
electrical  reaction  until  a  considerable  time,  often  many  years, 
has  elapsed,  and  then  only  a  slight  degree  of  atrophy  ensues, 
which  results  from  the  prolonged  inactivity.  But  the  observations 
of  Erb^  and  of  Ziemsseb  and  Weiss^  appear  to  contradict  this 
theory,  and  Yulpian,  as  we  have  seen,  has  even  met  with  a  more 
profound  alteration  of  muscle  after  simple  section  than  after  any 
other  injury  of  a  nerve.  It  seems  now  generally  admitted  that 
both  irritative  and  destroying  lesions  of  the  ganglion  cells  of 
the  anterior  horns  of  the  spinal  cord,  and  their  homologues  in 
the  medulla  oblongata,  pons,  and  crura,  or  of  the  efferent  fibres 
which  unite  these  cells  with  the  periphery  may  give  rise  to 
active  atrophy  of  muscle.  But  whether  the  same  kind  of  cell 
exercises  both  motor  and  trophic  functions,  or  there  exist  separate 
cells  for  each  function,  is  as  yet  undetermined. 

^  "  Note  sur  quelques  cas  d'affection  de  la  peau  dependent  d"une  influence  du 
systeme  nerveux,"  par  J.-M.  Charcot,  suivies  de  "  Eemarques  sur  la  mode 
d'influence  du  systeme  nerveux  sur  la  nutrition,"  par  le  docteur  Brown-Sequard. 
Journal  de  Physiolosie,  T.  II.,  1859,  p.  108. 

-  Erb  (W.).  "Zur  Patholosjie  und  pathologischen  Anatomie  peripherischer 
Paralysen."  Deutsches  Arch.  f.  klin.  Med.,  Bd.  IV.,  1868,  p.  539  (Gardolf's  case). 
Deutsches  Arch.  f.  klin.  Med.,  Leipzig,  Bd.  V.,  1866,  p.  44. 

^  Ziemssen  and  Weiss.  "  Die  Veranderungen  der  elektrischen  Erregbarkeit  bei 
traumatischen  Lahmungen."  Deutsches  Arch.  f.  klin.  Med.,  Leipzig,  Bd.  IV., 
1868,  p.  579. 

VOL.  I.  Q 


242  TROPHONEUEOSES. 

(IIL)-OUTANEOUS  TROPHIC  AFFECTIONS. 

§  114.  Erythema  and  Related  Conditions. — Erythema  is  pro- 
bably not  unfrequently  caused  by  a  functional  disturbance  of  the 
vaso-motor  or  trophic  cutaneous  nerves.  After  traumatic  lesions 
of  the  peripheral  nerves  circumscribed  cutaneous  red  patches  are 
often  observed  on  the  extremities,  resembling  chilblains,  some- 
times associated  with  a  pseudo- phlegmonous  swelling  of  the 
subcutaneous  cellular  tissue.  Transitory  and  recurring  patches 
of  erythema,  which  are  no  doubt  of  nervous  origin,  have  been 
observed  on  the  forehead  and  root  of  the  nose  in  connection  with 
trigeminal  neuralgia,  and  occasionally  on  the  hand  in  cases  of 
brachial  neuralgia.  Erythema  is  doubtless  frequently  of  reflex 
origin,  as  in  those  cases  which  arise  in  the  course  of  digestive 
disorders. 

Urticaria. — It  is  very  probable  that  the  urticaria  caused  by 
the  stings  of  insects  and  nettles,  as  well  as  that  which  arises  in 
the  neighbourhood  of  the  puncture  in  subcutaneous  injections, 
and  from  various  other  local  irritants,  is  due  to  nervous  irri- 
tation. The  suddenness  with  which  urticaria  occurs  in  some 
persons,  after  eating  shell-fish,  oatmeal,  and  other  articles  of 
diet,  would  appear  to  indicate  that  it  is  due  in  these  cases  to 
reflex  nervous  irritation. 

The  nervous  origin  of  urticaria  is,  however,  at  times  very 
striking.  Charcot  mentions  the  case  of  a  woman  suffering  from 
locomotor  ataxy,  who  at  every  paroxysm  of  lancinating  pains 
developed  enormous  patches  of  urticaria  over  the  parts  where 
the  severest  pains  were  felt. 

'  §  115.  Eczema,  Herpes,  and  other  Eruptions. — Vesicular 
eruptions  are  often  observed  after  injury  to  the  nerves.  Drs. 
Weir  Mitchell,  Morehouse,  and  Keen^  have  described,  under  the 
name  of  eczematous  eruptions,  an  affection  of  the  skin,  consisting 
of  minute  vesicles  thickly  scattered  over  the  tender  cutis,  or 
appearing  in  successive  crops  of  larger  vesicles,  and  occurring 
after  traumatic  nerve  lesions.  These  eruptions  are  limited  to 
the  area  of  distribution  of  the  injured  nerve,  and  are  usually 
associated  with  severe  neuralgic  pains ;   and  it  is  not  a  little 

I  "  Gunshot  Wounds  and  other  injuries  of  Nerves."    Philad. ,  1804.     p.  SO. 


TROPHONEUEOSES.  243 

remarkable  that  these  pains  often  decline  on  the  appearance  of 
the  eruption.  An  interesting  case  of  eczema  of  the  whole  left 
side  of  the  face  is  reported  by  Dr.  Cavafy/  which  had  succeeded 
to  a  severe  attack  of  trigeminal  neuralgia  in  which  all  the 
branches  of  the  nerve  were  implicated. 

Romberg^  was  the  first  to  draw  attention  to  the  very  frequent 
association  of  herpes  zoster  with  neuralgia,  and  to  lay  stress 
upon  the  analogy  of  this  eruption  with  the  redness  and  vesicular 
eruptions  which  occur  in  neuralgia,  and  after  injuries  of  nerves. 
But  a  remarkable  anticipation  of  the  neurotic  theory  of  herpes 
zoster  may  be  found  in  the  writings  of  Bright.^  Speaking  of 
the  bullae,  which  make  their  appearance  on  the  lower  extremities 
in  cases  of  acute  spinal  disease,  he  remarks :  "  It  has  sometimes 
struck  me  that  this  connection  between  interrupted  nervous 
action  and  the  formation  of  bullse  might  hereafter  be  found  to 
throw  light  on  the  relation  of  that  most  singular  disease,  herpes 
zoster,  which  from  the  peculiar  pain  with  which  it  is  accompanied 
as  well  as  from  its  strict  confinement  to  one  side  of  the  body 
seems  to  be  connected  with  some  peculiar  condition,  perhaps  the 
distension,  of  the  sentient  nerves."  The  favourite  seat  of  herpes 
zoster  is  the  skin  covering  one  or  more  of  the  intercostal  spaces. 
The  neuralgia  which  accompanies  it  generally  appears  with  the 
eruption,  and  in  aged  people  it  is  often  exceedingly  severe  and 
intractable,  and  generally  continues  long  after  the  eruption  has 
disappeared.  A  case  of  herpes  zoster  of  the  right  shoulder  is 
reported  by  JofFroy*  in  which  three  months  after  the  attack  the 
small  muscles  of  the  right  hand  were  found  atrophied.  He 
mentions  another  case  in  which,  after  severe  pains  in  the  left 
shoulder,  the  deltoid  muscle  of  the  same  side  became  atrophied. 
Under  treatment  the  patient  slowly  recovered;  but  at  the  end  of 
seven  months  an  eruption  of  herpes  zoster,  accompanied .  by 
severe  pain,  appeared  over  the  inner  and  posterior  surfaces  of 
the  left  forearm.  It  would  appear,  as  the  author  believes,  that  in 
both  of  these  cases  an  ascending  neuritis  had  taken  place  during 
the  first  attack,  and  that  the  second  was  caused  by  implication 

'  Cavafy  (J.).     British  Medical  Journal.     Vol.  II.,  1880,  p.  126. 
'■^  Romberg  (M.  H.).     A  manual  of  the  nervous  diseases  of  man.     Translated  by 
Ed.  H.  Sieveking,  M.D.     Lond.,  1853.     Vol.  I.,  p.  50. 

''  Bright  (E.).     Eeports  of  Medical  Cases.     Vol.  II.     Lond.,  1831.     p.  383. 
'  Jolfroy  (A.).     Arch,  de  physiologie.    Tome  IX.,  1882,  p.  170. 


244  TROPHONEUEOSES. 

of  the  fibres  of  other  nerves  at  a  point  of  union  in  the  brachial 
plexus,  Mr.  Jonathan  Hutchinson^  records  several  cases  of 
neuralgic  herpes  zoster  of  the  face,  which  were  attended  with 
iritis,  causing  serious  injury  to  the  affected  eye.  Out  of  fourteen 
cases  tabulated  by  him  the  frontal  nerve  was  affected  in  all ;  in 
seven  of  these  the  side  of  the  nose  was  also  involved,  and  in  five 
of  the  latter  seven  the  nasal  branches  were  implicated,  and  the 
cornea  and  iris  inflamed  in  all,  while  in  the  remaining  two  the 
trochlear  branches  were  alone  implicated  and  the  eye  did  not 
inflame.  An  interesting  case  of  herpes  zoster  in  the  region  of 
distribution  of  the  ophthalmic  branch  of  the  fifth  nerve  of  the 
right  side  is  recorded  by  Letulle  ;^  the  herpetic  eruption  was 
preceded  for  several  days  by  neuralgic  pains  in  the  part,  and  the 
vesicular  eruption  was  accompanied  by  erythema  and  cedema  of 
the  surrounding  skin,  which  spread  over  the  right  cheek  and 
over  both  temples.  On  the  eighth  day  from  the  commencement 
of  the  eruption  the  neuralgic  pains  disappeared,  and  were  fol- 
lowed by  a  distinct  diminution  of  the  sensibility  of  the  affected 
part,  while,  twenty  days  from  the  commencement,  the  patient 
manifested  an  incomplete  paralysis  of  the  right  facial  nerve. 
The  author  thinks  that  both  the  herpes  and  the  facial  paralysis 
were  caused  by  a  rheumatic  inflammation  of  the  ophthalmic 
branch  of  the  fifth,  and  the  facial  nerve  respectively,  the  latter 
complication  being  merely  accidental. 

In  1863,  Baerensprung^  had  an  opportunity  of  making  a 
post-mortem  examination  in  a  case  of  intercostal  herpes  zoster. 
Recklinghausen,  who  conducted  the  examination,  found  the 
intercostal  nerves  swollen  and  red,  and  presenting  all  the 
evidences  of  an  interstitial  neuritis  ;  the  corresponding  spinal 
ganglia  were  strongly  adherent  to  the  walls  of  the  intervertebral 
canal,  and  presented  the  ordinary  evidences  of  an  interstitial 
neuritis. 

In  1865  Charcot  and  Cotard*  reported  a  case  of  herpes  of  the 
neck  supervening  in  the  course  of  cancer  of  the  vertebral  column. 

'  Hutchinson  (J.).    London  Hospital  Eeports,  1866,  p.  68. 

-  Letulle  (Maurice).  "  Sur  un  cas  de  zona  ophthalmique  gangreneux  complique 
de  paralysis  faciale."    Arch,  de  Physiol.,  Tome  IX.,  1882,  p.  162. 

^  Baerensprung.  "  Beitrage  zur  Kenntniss  des  Foster."  Annalen  der  Cbarite, 
Bd,  XI.,  Heft  2,  1863,  p.  100. 

"  Charcot.  Lectures  on  the  Diseases  of  the  Xervous  System.  Xew  Syd.  Soc. 
Lond.,  1877.    p.  25. 


TROPHONEUROSES.  245 

The  spinal  ganglia  and  the  cervical  nerves  appeared  swollen  and 
red,  and  presented  the  histological  characters  of  an  interstitial 
inflammation.  A  curious  case  of  recurring  ophthalmic  herpes 
zoster  is  recorded  by  Nieden/  which  seems  to  show  that  the 
affection  is  sometimes  caused  by  lesion  of  the  cilio-spinal  region 
of  the  spinal  cord  and  of  the  cervical  sympathetic.  The  patient 
suffered  from  five  attacks  of  the  eruption  in  six  years.  The 
cause  assigned  by  the  patient  for  these  attacks  was  a  blow  he 
received  in  1869  by  the  stem  of  a  tree  falling  on  the  back  of  his 
neck.  On  examination  the  transverse  processes  of  the  second, 
third,  and  fourth  c^vical  vertebrse  were  considerably  thickened, 
the  vertebrse  themselves  were  dislocated  to  the  right  and  sensi- 
tive to  pressure.  Each  attack  begins  with  intense  headache,  the 
left  half  of  the  face  is  hypersesthetic,  reddened,  and  covered  with 
sweat;  the  conjunctiva  is  congested;  there  is  a  free  flow  of  tears; 
and  the  pupil  is  contracted  and  only  becomes  dilated  to  a  slight 
degree  by  atropine.  During  this  time  the  patient  suffers  from 
prsecordial  anxiety  and  palpitation,  and  a  few  days  after  the  first 
appearance  of  these  symptoms,  the  left  halves  of  the  forehead, 
nose,  and  eyelids  become  covered  by  an  eruption  of  herpes,  when 
the  pain  remits.  The  author  thinks  that  there  is  a  secondary 
affection  of  the  superior  cervical  sympathetic  ganglion  of  the 
left  side. 

Spinal  and  Cerebral  Eruptions. — Eruptions  of  zoster  fre- 
quently occur  in  chronic  myelitis,  and  especially  in  tabes  dorsalis, 
and  the  fact  that  they  are  always  limited  to  nerve  territories 
affected  with  neuralgic  and  lightning  pains,  shows  that  they  are 
undoubtedly  of  spinal  origin.  Cases  of  this  kind  have  been 
recorded  by  Charcot,^  Buzzard,^  and  many  other  authors.  I  have 
had  an  opportunity  a  few  days  ago  of  witnessing  an  eruption  of 
herpes  on  the  nates  of  a  patient  suffering  from  locomotor  ataxy. 
The  eruption  appeared  for  the  first  time  six  months  ago,  and 
since  that  time  the  patient  has  had  an  attack  on  an  average 
every  month ;  each  attack  lasts  about  six  days,  the  eruption  is 
excessively  painful,  and  always  supervenes  during  an  attack  of 
lancinating  pains.     Herpes  is  not  unfrequently  associated  with 

1  Nieden  (A.).     Neurologlsche  Centralbl.    Bd.  I.,  1882,  p.  374. 
'^  Charcot.    Lectures  on  the  Diseases  of  the  Nervous  System.     Translated  by 
G-.  Sigerson,  M.D.    New  Syd.  Soc,  1877,  p.  20. 
=  Buzzard.    Brain.     Vol.  I.,  1879,  p.  168. 


246  TROPHONEUEOSES. 

hemiplegia,  but  it  is  somewhat  doubtful  whether  there  is  any- 
thing more  than  an  accidental  connection  between  them.  Dr. 
Duncan^  reported  the  cases  of  two  aged  women  who  were  attacked 
with  hemiplegia,  and  in  each  of  whom  an  eruption  of  herpes 
appeared  on  the  affected  side  almost  simultaneously  with  the 
motor  paralysis.  The  case  of  a  child  is  recorded  by  Dr.  Payne,^ 
who  had  an  eruption  of  herpes  in  the  region  of  distribution  of 
the  superficial  branches  of  the  anterior  crural  nerve  three  days 
after  an  attack  of  temporary  hemiplegia  of  the  same  side. 
Charcot^  relates  the  case  of  a  young  soldier,  twenty-two  years  of 
age,  who  was  simultaneously  attacked  with  hemiplegia  and  a 
vesicular  eruption  in  the  inferior  extremity  of  the  paralysed  side, 
in  the  region  of  the  distribution  of  the  superficial  twigs  of  the 
cutaneous  peroneal  branch  of  the  musculo-cutaneous  nerve.  At 
the  post-mortem  examination  it  was  proved  that  the  hemiplegia 
was  caused  by  a  focus  of  softening  determined  by  embolus  of  a 
posterior  cerebral  artery  ;  but  the  herpes  was  produced  by  a 
totally  different  mechanism,  A  spinal  arterial  branch,  probably 
arising  from  one  of  the  lateral  sacral  arteries,  was  also  found 
obliterated  by  a  blood-clot,  forming  a  comparatively  voluminous 
cord,  and  adhering  to  one  of  the  posterior  spinal  roots  of  the 
Cauda  equina.  Charcot  thinks  that  this  artery,  distended  by  the 
embolus,  had  compressed  one  of  the  spinal  ganglia,  or  an  initial 
branch  of  the  sciatic  nerve ;  so  that  the  herpetic  eruption  in  this 
case  would  really  be  of  peripheral  and  not  of  cerebral  origin. 
This  case  throws  considerable  doubt  on  the  cerebral  origin  of 
the  other  cases  described,  especially  as  the  phenomena  observed 
were  not  checked  by  careful  post-mortem  examinations. 

Pemphigus  bullce  may  also  develop  with  great  rapidity  over 
various  parts  of  the  surface  supplied  by  the  cutaneous  branches 
of  an  injured  nerve;  and  these,  according  to  Charcot,*  almost 
always  leave  after  them  indelible  scars. 

Bullous  eruptions  are  also  of  spinal  origin,  as  in  a  case  ob- 

^  Duncan  (J.).  "  On  Herpes  Zoster."  Journal  of  Cutaneous  Medicine,  &c.,  by 
Erasmus  Wilson.    Vol.  II.,  1868,  p.  241. 

■"  Payne.    British  Medical  Journal.     Vol.  II.,  1871,  p.  242. 

"  Charcot.  On  the  Diseases  of  the  Nervous  System.  New  Syd.  Soc.  Lond.,  1877. 
p.  64. 

*  Charcot.  Ibid.,  p.  2.  See  also  Russell.  "  Cases  of  pemphigus  apparently 
originating  in  disease  of  the  cutaneous  nerves. "  Medical  Times  and  Gazette,  Vol.  II. , 
1864,  p.  464. 


TKOPHONEUROSES.  247 

served  by  Balmer/  where  an  attack  of  pemphigus  occurred  in 
the  course  of  progressive  muscular  atrophy.  In  a  remarkable 
case  of  general  paralysis  accompanied  by  sclerosis  of  the  lateral 
columns  of  the  spinal  cord,  communicated  by  D^jerine,^  the  arms 
and  legs  became  covered  by  a  pemphigus  eruption  six  or  seven 
days  before  death.  Besides  the  post-mortem  appearances  char- 
acteristic of  lateral  sclerosis  in  the  cord,  the  cutaneous  nerves 
underlying  the  bullge  were  found  to  have  undergone  degenerative 
changes.  Evidences  of  degenerative  atrophy,  such  as  segmenta- 
tion of  myeline,  disappearance  of  axis  cylinders,  and  multiplication 
of  nuclei,  were  found  by  Leloir^  in  the  cutaneous  nerves  subjacent 
to  the  bullae  of  chronic  pemphigus.  Several  cases  of  pemphigus 
in  connection  with  spinal  disease  have  been  recorded  by 
Chovstek.* 

That  pemphigus  is  sometimes  caused  by  cerebral  lesions 
is  rendered  probable  by  several  cases.  In  one  observed  by 
Hesselink,^  a  pemphigus  eruption  appeared  after  an  apoplectic 
attack,  and  disappeared  along  with  the  hemiplegia.  In  another, 
communicated  by  Chovstek,^  huWse  appeared  on  the  outer  edge  of 
the  paralysed  foot  on  the  fourth  week  after  an  attack  of  right- 
sided  hemiplegia,  which  was  preceded  by  neuralgic  pains.  The 
post-mortem  examination  showed  that  the  hemiplegia  was  due 
to  a  haemorrhage  in  the  left  temporal  lobe  and  lenticular 
nucleus.  The  occurrence  of  a  bullous  eruption  in  the  early 
stages  of  acute  bed-sores  also  shows  the  occasional  dependence 
of  the  affection  on  spinal  and  cerebral  lesions. 

Papular  eruptions  are  sometimes  caused  by  lesions  of  the  nervous 
system.  Cliarcot  states  tliat  it  is  not  rare  to  see  tlie  skin  of  the  legs  and 
thighs  temporarily  covered  with  a  papular  eruption  during  paroxysms  of 
the  lancinating  pains  characteristic  of  locomotor  ataxy.  Some  liathologists 
believe  that  Hchen  planus  and  other  chronic  papular  eruptions  are  always 
of  neurotic  origin,  and  that  they  usually  occur  in  patients  who  are  suffering 

*  Balmer.  "  Hautstorungen  bei  der  Progressive!!  Muskelatrophie."  Arch,  f iir 
Heilkunde,  1875,  p.  335. 

*  Dejerine.  "  Paralysie  general. — Troubles  trophiques,"  &c.  Arch,  de  Physiol., 
Tome  III.,  1876,  p.  317. 

=  Leloir.    Progres  m^d.     Tome  IX.,  1881,  p.  235. 

*  Chovstek.  Weitere  Beitrage  zu  den  vasomotorischen  und  trophischen  Nerven. 
Centralbl.  f.  med.  Wissensch.,  1876,  p.  56. 

'  See  Eiilenburg  (A.).  Lehrbuch  der  ISTervenkrankheiten.  2  Aufl.  Bd.  I., 
1878,  p.  341. 

°  Chovstek.    Wiener  Med.  Wochenschr.,  1875,  No.  32. 


248  TROPHONEUEOSES. 

from  nervous  depression  and  other  symptoms  of  an  over-strained  nervous 
system.^  According  to  Charcot  pustular  eruptions  analagous  to  ecthyma, 
and  leading  to  deep  ulcerations,  may  also  be  developed  during  the  paroxysms 
of  the  lightning  pains  in  tabes.     Vulpian^  also  reports  similar  cases. 

Ichthyosis  and  other  Scaly  Diseases. — After  section  or  injury, 
of  nerves  the  skin  frequently  becomes  dry,  harsh,  and  scaly.* 
Eulenburg*  reports  a  case  in  which  several  branches  of  the 
brachial  plexus  were  compressed  in  consequence  of  a  dislocation 
of  the  humerus,  and  in  which  ichthyosis  of  the  skin  of  the 
affected  extremity  had  supervened.  In  perforating  ulcer  of  the 
foot,  now  supposed  to  be  due  to  disease  of  the  peripheral  nerves, 
not  only  do  callosites  form  on  the  sole,  but  the  skin  on  the 
dorsum  is  often  also  thickened  and  scaly.  In  a  case  of  nerve 
irritation  observed  by  Fischer,^  exfoliation  of  the  skin  occurred 
in  streaks  corresponding  to  the  branches  of  the  affected  nerve, 
the  intermediate  skin  being  healthy.  Several  cases  of  injury  of 
peripheral  nerves  are  recorded  by  Schiefferdecker,^  in  which  the 
skin  in  the  region  of  distribution  of  the  affected  nerve  had 
become  thickened,  scaly,  and  of  a  brown  colour,  and  the  hair 
and  nails  hypertrophied  ;  the  affected  extremity  was  bathed  in 
sweat  having  a  bad  odour,  and  its  temperature  was  lowered. 
Ichthyosis  of  the  lower  extremities  occurs  not  unfrequently  in 
cases  of  Pott's  curvature  and  in  chronic  spinal  diseases.  Leloir'^ 
made  a  microscopical  examination  of  the  nervous  system  in  two 
cases  that  died  while  labouring  under  ichthyosis,  and  he  found 
atrophic  changes  in  the  peripheral  nerves  and  the  anterior  and 
posterior  roots,  but  as  the  patients  suffered  from  pemphigus 
bullae  before  death  the  results  obtained  are  inconclusive. 

A  very  curious  affection,  which  appears  to  belong  to  the  scaly 
eruptions,  probably  a  local  ichthyosis,  was  first  described  by 
Baerensprung^  under  the  name  of  "  Naevus  unius  lateris,"  and 

1  See  Fox  (T.  Colcott).    British  Medical  Journal.    Vol.  I.,  1880,  p.  398. 
^  Vulpian.     Maladies  du  Systeme  nerveux.     Paris,  1879.     p.  338. 
^  Mitchell,  Morehouse,  and  Keen.     Gunshot  Wounds  and  other  injuries  of  the 
nerves.    Philad.,  1864. 

*  Eulenburg.    Deutsche  klin.  Wochenschrift,  No.  3,  p.  26. 

*  Fischer.     Berl.  klin.  Wochenschr.,  1875,  Nos.  32,  33. 

«  Schiefferdecker.     Centralbl.  f.  med.  Wissensch.    Vol.  IX.,  1871,  p.  283. 
■"  Leloir.     Op.  cit.,  p.  68. 

^  Baerensprung.  "Naevus  unius  lateris."  Annalen-Charit^.  Berl.,  1863. 
Bd.  XI.,  Heft  2,  p.  91. 


.  TROPHONEUROSES.  249 

afterwards  by  Gerhardt^  as  "  neuropathic  cutaneous  papilloma," 
and  by  Simon^  as  "  nerve-naevi."  The  affection  consists  of  a 
number  of  papillary  elevations,  each  varying  in  size  from  a  pin's 
head  to  a  fourpenny  piece  or  even  larger.  Each  spot  is  slightly 
raised  from  the  surface,  of  a  brown  colour,  and  covered  by  a  scaly 
epithelium  which  can  be  readily  scraped  off.  The  spot  appears 
to  be  caused  by  a  hypertrophy  of  the  papillee,  thickening  of  the 
epidermis,  and  pigmentation  of  the  rete  malpighi.  The  chief 
peculiarities  of  the  affection  are  that  it  dates  its  origin  from 
birth ;  that  the  spots  form  streaks  and  more  or  less  extensive 
groups  which,  like  herpes  zoster,  are  always  distributed  along 
the  track  of  particular  cutaneous  nerves ;  and  that,  like  zoster 
also,  it  is  always  limited  to  one  side  of  the  body,  and  never 
crosses  the  middle  line.  At  times  no  disease  of  the  nervous 
system  can  be  discovered,  but  it  is  sometimes  found  associated 
with  grave  organic  nervous  disease,  such  as  pseudo-hypertrophic 
paralysis^  and  idiocy  (Gerhardt). 

§  116.  Glossy  SJdn. — The  affection  which  has  been  termed 
"glossy  skin"  was  first  described  by  Paget,  who  justly  regarded 
it  as  "a  sign  of  peculiarly  impaired  nutrition  and  circulation 
due  to  injury  of  nerves."  "In  well-marked  cases,"  says  Paget,* 
"  the  fingers  which  are  affected  (for  this  appearance  may  be 
confined  to  one  or  two  of  them)  are  usually  tapering,  smooth, 
hairless,  almost  void  of  wrinkles,  glossy,  pink  or  ruddy,  or 
blotched  as  with  permanent  chilblains.  They  are  commonly 
also  very  painful,  especially  on  motion,  and  pain  often  extends 
from  them  up  the  arm."  The  American  surgeons^  also  drew 
special  attention  to  this  condition,  which  was  frequently  observed 
by  them  in  connection  with  traumatic  lesions  of  nerve  trunks. 
According  to  their  observations,  when  a  single  nerve,  as  the 


^  Gerhardt.  Jahrbucher  flir  Kinderkrankheiten.  IV.  Jahrgang,  Heft  3. 
Leipzig,  1871.     p.  270. 

*  Simon  (Th.).  Ueber  "Nerven-naevi."  Arch,  fiir  Dermat.  und  Syph.,  Bd.  IV., 
1871,  p.  24. 

^Crocker  (H.  R.).  "A  case  of  papillary  growths  in  the  course  of  nerves." 
Medical  Times  and  Gazette,  Vol.  I.,  1880,  p.  633.  See  also  Mackenzie  (Stephen), 
Medical  Times  and  Gazette,  Vol.  .1.,  1880,  p.  451;  and  Gowers,  Pseudo-hyper- 
trophic paralysis,  p.  9. 

*  Paget.     Medical  Times  and  Gazette,  London,  Vol.  I.,  18G4,  p.  332. 
^  Mitchell,  Morehouse,  and  Keen.     Op.  cit.,  1864,  p.  78. 


250  TROPHONEUROSES. 

ulnar,  is  injured,  this  condition  of  skin  is  observed  in  the  fingers 
or  toes ;  but  in  instances  of  more  extensive  nerve  injury  the 
palm  of  the  hand  often  becomes  affected,  but  it  is  rare  for  the 
dorsum  to  be  implicated.  In  the  foot,  on  the  other  hand, 
the  reverse  condition  obtains,  the  dorsum  being  the  part  most 
liable  to  suffer.  In  a  case  of  neuritis  of  the  ulnar  nerve,  under 
my  care,  in  a  woman  who  had  to  do  much  manual  labour,  the 
skin  of  the  inner  or  ulnar  half  of  the  palm  was  much  atrophied, 
and  was  separated  from  that  of  the  outer  half  by  a  well  marked 
linear  ridge.  The  first  impression  made  upon  almost  all  the 
many  students,  to  whom  the  case  was  pointed  out,  was  that  the 
affection  consisted  of  a  hypertrophy  of  the  skin  of  the  palm 
supplied  by  the  median  nerve.  "  Glossy  skin  "  appears  to  be,  as 
Charcot  remarks,  due  to  a  peculiar  inflammation  of  skin  analagous 
to  the  condition  known  as  scleroderma.  Severe  pain,  sometimes 
of  a  peculiar  burning  character,  is  found  associated  with  this 
morbid  condition  of  the  skin. 

Myxoedema. — In  this  affection,  which  occurs  exclusively  in 
adult  women,  the  subcutaneous  tissues  are  swollen,  and  the 
patient  presents  an  appearance  more  or  less  like  a  person  suffer- 
ing from  renal  anasarca.  In  the  former  disease,  as  in  the  latter, 
the  eyelids  are  puffy,  the  lips  are  prominent,  the  face  is  swollen, 
and  the  hands  are  large,  clumsy,  and,  to  use  Sir  W.  Gull's  apt 
illustration,  "  spade -like."  In  myxoedema,  however,  the  oedema 
is  caused  by  a  deposit  of  a  mucoid  substance  in  various  parts  of 
the  body,  and  consequently  the  skin  feels  solid  and  resilient  to 
touch,  instead  of  being  soft  and  boggy,  as  it  is  in  ordinary  oedema. 
The  skin  is  dry,  harsh,  and  often  rough,  and  the  temperature  of 
the  body  is  always  below  normal.  Nervous  symptoms  are 
generally  present,  and  constitute  an  important  element  in  the 
clinical  picture  of  the  disease  ;  they  consist  of  general  blunting 
or  at  least  great  retardation  of  the  cutaneous  sensibility,  perver- 
sion of  the  special  senses,  sometimes  with  hallucinations  and 
delusions,  sluggish  and  drawling  speech,  and  at  times  loss  of 
memory,  incoherence,  and  even  acate  mania.  Nothing  certain 
is  known  with  regard  to  the  pathology  of  this  affection.  The 
disease  was  first  described  by  Sir  W.  GulP  as  a  "  cretinoid  state 

1  Gull.   "  On  a  cretinoid  state  supervening  in  adult  life  in  women."   Transactions 
of  the  Clinical  Society,  Vol.  VII.,  p.  57. 


TROPHONEUKOSES.  251 

supervening  in  adult  life  in  women."  Ord^  subsequently  named 
it  myxoedema ;  and  Charcot,^  who  described  it  under  the  name 
"  cachexie  pachydermique,"  met  with  the  disease  in  the  male. 
Some  pathologists^  regard  it  as  being  caused  by  Bright's  disease, 
while  others  believe  that  disease  of  the  nervous  system  plays 
an  important  part  in  its  production.  Dr.  Ord  thinks  that  the 
nervous  symptoms  are  caused  by  the  compression  of  the  peri- 
pheral termination  of  the  nerves  by  mucoid  tissue;  while  Charcot, 
Savaofe,*  and  Hammond^  think  that  lesion  of  the  brain  and  other 
nerve  centres  is  the  primary  element  in  its  production, 

§  117.  Alteration  in  the  Pigmentation  of  the  SJcin — Partial 
Leucoderma — Bronzed  SJcin,  Ncevi  Pigmentosi. — In  partial 
leucoderma,  or  vitiligo,  circular  patches  of  the  skin  are  deficient 
in  pigment,  giving  a  white  appearance  to  the  affected  part,  which 
is  more  striking  by  contrast  in  the  coloured  races.  In  these 
patches  the  hairs  are  often  white,  and  cutaneous  sensibility  is 
bluDted.  Patches  of  leucoderma  are  sometimes  observed  on  the 
face  in  trigeminal  neuralgia,  and  in  unilateral  facial  atrophy. 
Similar  patches  have  been  observed  by  Eulenburg^  after  in- 
juries to  the  larger  nerve  trunks.  The  affection  has  also  been 
observed  to  arise  after  severe  emotional  disturbance,^  or  in 
connection  with  central  affections  of  the  nervous  system,  as 
exophthalmic  goitre,^  showing  its  frequent  dependence  on 
disease  of  some  part  of  the  nervous  system.  Increase  of  pigment 
of  the  skin,  either  partial  or  diffused,  also  appears  often  to 
depend  on  nervous  disease.  A  curious  case  of  pigmentation  of 
the  skin  is  reported  by  Dr.  W.  Alexander,^  as  occurring  in  a 
girl  aged  18  years.     The  pigmentation  formed  yellowish- brown 

'  Ord.  "  On  myxoedema,  a  term  proposed  to  be  applied  to  an  essential  condition 
in  the  cretinoid  affections  observed  in  middle-aged  women."  Medico-chirurgical 
Transactions,  LXI.,  1878,  p.  57;  and  British  Medical  Journal,  Vol.  L,  1878,  p.  671. 

2  Charcot  et  Ballet.    Le  Progres  med.     Tome  VIII.,  1880,  p.  605. 

^  Mohamed.  "  The  pathology  and  etiology  of  myxoedema."  Lancet,  Vol,  II., 
1880,  p.  1078. 

*  Savage.     Journal  of  Mental  Science,  January,  1880,  p.  417. 

*  Hammond.     Diseases  of  the  Nervous  System.     7th  edit.  1881,  p.  334, 

°  Eulenberg  and  Gruttmann,   Pathology  of  the  Sympathetic.   Lond.,  1879.   p.  108. 

''  Beigel.  "  Albinismus  und  Nigrismus,"  Virchow's  Arch.,  Bd.  XLIII.,  1868, 
p.  529. 

**  Eaynaud.     Vitiligo  et  Goitre  Exophthalmique.     These  de  Paris,  1875. 

"Alexander  (W.).  "On  some  rare  forms  of  disease  accompanied  by  lesions  of 
trophic  nerves  or  trophic  centres."    The  Lancet,  Vol»  I.,  1881,  p.  98(\ 


252  TROPHONEUROSES. 

patches,  which  were  scattered  irregularly  but  symmetricallj'-  all 
over  the  body.  The  patches  of  pigmented  skin  were  found 
constantly  anaesthetic.  The  bronzing  of  the  skin  in  Addison's 
disease  is  probably  due  primarily  to  an  affection  of  the  nervous 
apparatus.^  The  skin  has  been  observed  to  become  rapidly 
discoloured  after  severe  emotional  disturbances;  and  a  case  is 
related  by  Rostan  of  a  woman  under  sentence  of  death,  whose 
skin  became  in  a  few  days  of  a  dark  colour,  which  graduall)'- 
disappeared  on  the  sentence  being  commuted.  It  is  also  probable 
that  some  of  the  collections  of  pigment  in  the  rete  called 
pigmentcury  ncevi  have  a  nervous  origin.  The  nerve  filaments 
distributed  to  the  affected  patches  of  skin  in  vitiligo  have  been 
examined  microscopically  by  Leloir^  and  Ddjerine,^  who  found 
similar  changes  to  those  observed  in  the  Wallerian  degeneration. 
Lepra  Ancesthetica — Elephantiasis  GrcBcorum. — The  early 
occurrence  and  severe  degree  of  anaesthesia  in  the  tubercular 
variety  of  leprosy,  as  well  as  the  manner  in  which  it  progresses 
from  the  periphery  towards  the  central  parts  of  the  affected 
limbs,  would  alone  indicate  that  disease  of  some  part  of  the 
nervous  system  is  a  prominent  part  of  the  affection.  Character- 
istic anatomical  changes  have  also  been  found  both  in  the  nerve 
trunks  and  in  the  spinal  cord  and  brain,  although  it  is  probable 
that  the  alterations  in  the  nerve  centres  are  of  a  secondary 
nature. 

According  to  the  observations  of  Yircliow*  the  morbid  process  begins  in 
this  form  of  leprosy,  with  a  perineuritis,  causing  interstitial  cell  prolifera- 
tion to  such  a  degree  that  the  nerve  tubes  become  atrophic  through  com- 
pression. Dr.  Vandyke  Carter^  found  the  brain,  spinal  cord,  and  roots  of 
the  nerves  healthy  in  ten  cases  of  leprosy  ;  while  the  nerve  trunks,  on  the 
other  hand,  were  swollen,  dull  red,  or  grey,  or  semi-translucent,  romaded 
and  firm.  The  morbid  changes  were  found  chiefly  in  the  compound 
trunks,  which  are  situated  most  superficially,  and  in  the  cutaneous  nerves 
just  after  perforating  the  deep  fascia  ;  the  nerves  most  frequently  afi'ected 

1  Marchand  (Felix).  "  Ueber  eine  eigenthumliche  Erkrankung  des  Sympatliicus, 
der  Nebennieren  und  der  peripherischen  ISTerven  (ohne  Bronzehaut)."  Virchow's 
Archiv.,  Bd.  LXXXI.,  1880,  p.  477. 

*  Leloir.  Kecherches  sur  les  affections  cutanees  d'origine  nerveuse.  Paris, 
1882.    p.  48. 

«  Dejerine.     Progres  Med.     Tome  IX.,  1881,  p.  567. 

*  Virchow.  Du  krankhaften  Geschwiilste  "  Nerven-Lepra."  Bd.  II.,  1864-5, 
p.  521. 

*  Carter.     Transactions  of,  the  Pathological  Society  of  London,  1862,  p.  13. 


THOPHONEUROSES.  253 

being  the  supraorbital,  great  auricular,  ulnar,  median,  and  radial.  These 
observations  have  been  confirmed  by  various  other  authors.^  It  is,  however, 
maintained  by  Leloir^  that  a  parenchymatous  neuritis  is  present  along  with 
the  interstitial  neuritis,  and  he  is  inclined  to  believe  that  the  former  is 
primary  and  the  latter  secondary.  Drs.  Danielssen  and  Bock*^  state  that 
the  spinal  cord  and  its  membranes  are  altered.  The  cord  was  found  in- 
durated, and  its  grey  matter  discoloured,  yellowish,  and  devoid  of  vessels. 
The  membranes  were  infiltrated  with  an  albuminous  deposit,  a  layer  being 
found  between  the  arachnoid  and  pia  mater.  The  sheaths  of  the  nerves 
and  the  various  ganglia  were  similarly  aftected.  In  a  case  published  by 
Steudener  the  posterior  grey  horns  of  the  cord  were  found  softened,  and 
Neumann*  found  in  the  related  disease  of  leprous  pemphigus  thickening  of 
the  adventitise  of  the  spinal  vessels,  and  the  grey  substance  transformed 
into  a  colloid  mass.  In  a  case  of  lepra  autesthetica  reported  by  Langhaus," 
the  posterior  grey  horns  of  the  cord,  the  columns  of  Clarke,  and  the  grey 
commissure  were  found  softened,  the  morbid  changes  being  especially 
marked  in  the  upper  part  of  the  dorsal  region  and  in  the  cervical  enlarge- 
ment. Tschirjew®  observed  thickenings,  haemorrhages,  and  infiltrations, 
along  with  atrophy  of  the  cells  in  the  posterior  grey  horns  of  the  cervical 
region,  while  atrophic  changes  of  the  cells  of  Clarke's  vesicular  column  were 
found  in  the  dorsal  and  lumbar  regions.  The  anterior  grey  horns  and 
anterior  roots  were  throughout  normal. 


§  118.  Bed-sores  and  Related  Conditions. 

Decubitus  Acutus.- — The  rapid  development  of  bed-sores  in 
connection  with  severe  spinal  and  cerebral  lesions  has  been 
specially  studied  by  Samuel,  and  more  recently  by  Charcot ;''' 
although,  indeed,  Bright^  and  Brodie^  directed  attention  to  the 
affection  many  years  ago.  The  bed-sore  usually  occupies  the  sacro- 
gluteal  regions,  but  it  may  appear  on  any  part  of  the  trunk  and 
limbs  which  is  subjected  to  a  somewhat  continuous  pressure.    In 

'  See  Hoggan  (G-.  and  F.  E.).  Etude  sur  les  changements  subis  par  le  systeme 
nerveux  dans  la  lepre.     Arch,  de  Physiol.,  Tome  IX.,  1882,  p.  83. 

"  Leloir  (Henri).  Kecherches  cliniques  et  anatomo-pathologiques  sur  les  affec- 
tions cutanees  d'origine  nerveux.     Paris,  1882.     p.  131. 

^  Danielssen  et  Bock.  Traits  de  la  Spinalskhed.  Paris,  1848.  Quoted  in  Vir- 
chow's  krankhaften  Geschwlilste,  Bd.  II.,  p.  520. 

*  Neumann.  Text-book  of  Skin  Diseases.  Translated  by  A.  Pullar.  London, 
1871.    p.  273. 

^  Langhaus.  "  Zur  casuistik  der  Euckenmacksaffectionen  (Lepra  ansesthetica)." 
Virchow's  Arch.,  Bd.  LXI V.,  1875,  p.  175, 

"  Tschirjew.     Arch,  de  Physiologic,  1879. 

''  Charcot.     Op.  cit.,  p.  69. 

"  Bright.     Reports  of  Medical  Cases.    Vol.  II.    London,  1831.     p.  421. 

='  Brodie  (B.).     Medico-Chir.  Transact.    Vol.  XX.,  1837,  p.  148. 


254  TEOPHONEUEOSES. 

some  exceptional  cases  the  affection  is  produced  in  the  entire 
absence  of  pressure,  or  any  other  recognisable  exciting  cause. 

Some  days  or  even  hours  after  the  occurrence  of  a  severe 
spinal  or  cerebral  lesion,  or  after  a  sudden  exacerbation  of  these 
affections,  one  or  several  erythematous  patches,  of  variable 
extent  and  irregular  form,  appear  on  certain  points  of  the  skin. 
The  skin  has  a  rosy  hue ;  sometimes  it  is  dark  red  or  violet,  but 
the  colour  momentarily  disappears  ou  pressure  with  the  finger. 
Within  twenty-four  or  forty-eight  hours  the  central  part  of  the 
erythematous  patch  is  covered  with  vesicles  or  bullae,  the  con- 
tents of  which,  at  first  colourless  and  transparent,  become  more 
or  less  opaque,  reddish,  or  brown-coloured.  Under  favourable 
circumstances  the  vesicles  may  wither,  dry  up  and  disappear,  and 
the  part  recover  without  further  change  (Charcot).  As  a  rule, 
however,  the  vesicles  burst,  and  leave  ill-looking  ulcerations,  the 
bases  of  which  are  composed  of  the  true  skin  infiltrated  with 
blood,  and  usually  in  a  state  of  phlegmonous  inflammation.  In 
such  cases  the  subcutaneous  connective  tissue,  and  even  the  sub- 
jacent muscles,  are  infiltrated  with  blood.  The  base  of  the  ulcer 
soon  perishes  by  gangrene ;  the  neighbouring  skin  becomes  in- 
flamed to  a  greater -and  greater  extent;  and  the  gangrenous 
destruction  extends  deeper  and  deeper,  laying  bare  and  including 
in  its  destructive  operation,  muscles,  tendons,  fasciae,  ligaments, 
and  even  the  subjacent  bones. 

One  of  the  most  remarkable  characteristics  of  this  affection  is 
the  rapidity  of  its  development,  the  entire  cycle  of  changes  being 
completed  in  a  few  days.  Cystitis  and  hsematuria  are  not  ud- 
frequent  complications  of  this  condition,  and  the  muscles  often 
become  the  subjects  of  rapid  atrophy. 

Sequelce. — Such  extensive  gangrene  soon  gives  rise  to  a  more 
or  less  remittent  fever,  with  severe  chills,  and  great  variations 
of  temperature.  It  may  also  cause  purulent  infection,  with 
production  of  metastatic  abscesses  in  the  viscera,  which  are 
principally  observed  in  the  lungs.  The  fatal  result  in  these  cases 
is  preceded  by  general  marasmus.- 

One  other  complication  is  worthy  of  notice.  The  gangrenous 
process  extends  to  the  sacral  bones  ;  and  with  the  destruction  of 
the  sacro-coccygeal  ligament  the  vertebral  canal  is  opened,  so 
that  the  pus  and  the  gangrenous  ichor  have  now  ready  access  to 


TROPHONEUROSES.  255 

the  fatty  cellular  tissue  which  surrounds  the  dura  mater ;  or  they 
may  penetrate  this  membrane,  and  thus  make  their  way  to  the 
cavity  of  the  arachnoid.  This  grave  accident  gives  rise  either 
to  a  simple  purulent  or  to  an  ichorous  ascending  meningitis, 
which  rapidly  reaches  the  base  of  the  brain,  and  leads  to  a  fatal 
result.^ 

Simple  Chronic  Decubitus. — Chronic  bed-sore  arises  usually 
in  a  somewhat  different  way.  In  chronic  diseases  of  the  spinal 
cord  the  portions  of  skin  subjected  to  pressure  in  sitting  and 
lying  assume  a  dark  red  colour,  and  at  times  become  covered 
with  superficial  ulcerations.  After  a  time  a  black  spot  appears 
on  the  reddened  portion  of  skin,  and  if  the  pressure  is  continued, 
it  enlarges  rapidly,  and  the  affected  skin  dries  up  into  a  hard 
leathery  mass.  In  a  short  time  a  boundary  line  of  inflammation 
forms  around  the  gangrenous  portion  of  skin,  and  the  latter  may, 
under  proper  treatment,  be  thrown  off,  leaving  a  more  or  less 
healthy  granulating  surface,  which,  under  favourable  circum- 
stances, may  cicatrise. 

But  if  the  pressure  be  continued,  or  if  the  primary  disease  of 
the  nervous  system  undergo  a  fresh  exacerbation,  the  ulcerated 
surface  assumes  a  dark  violet  colour,  the  gangrene  spreads 
rapidly,  and  all  the  destructive  changes  characteristic  of  acute 
bed-sore  make  their  appearance,  and  soon  lead  to  a  fatal 
result  (Erb). 

This  form  of  gangrene  may  occur  at  any  place  exposed  to  continued 
pressure ;  but  its  favourite  sites  are  the  coccyx  and  buttocks,  the  trochanters 
and  ischiatic  protuberances,  heels,  knees,  the  spinous  processes  of  the  ver- 
tebra, the  shoulder  blades,  and  elbows. 

The  exciting  causes  of  bed-sore,  besides  continuous  pressure,  are  neuro- 
paralytic hypereemia,  complete  immobility  of  the  paralysed  parts,  aljseuce 
of  sensation,  and  the  irritation  caused  by  discharges  from  the  bladder  and 
rectum.  But  although  these  greatly  favour  the  formation  of  bed-sores,  yet 
they  are  of  themselves,  either  separately  or  combined,  inadequate  to  pro- 
duce the  more  acute  form  of  the  affection ;  and  the  latter  may  form  even 
after  every  precaution  in  the  way  of  cleanliness  and  protection  of  the  parts 
has  Ijeen  taken  to  prevent  it.  It  is  necessary,  therefore,  to  assume  a  grave 
lesion  of  trophic  fibres  and  centres,  as  being  operative  in  the  formation  of 
acute  bed-sore.  Acute  decubitus  is  found  associated  with  severe  traumatic 
lesions  of  the  cord,  acute  myelitis,  h^matomyelia,  and  it  has  been  observed 

'Charcot.   The  diseases  of  the  nervous  system.   New  Syd.  Soc.    Lend.,  1877.   p.  74. 


256  TROPHONEUKOSES. 

in  unilateral  lesions  of  the  cord,  not  on  the  paralysed  side  but  on  the 
ansesthetic  side.  This  fact  appears  to  show  that  the  cutaneous  trophic 
fibres  decussate  in  the  cord,  like  the  sensory  fibres.  It  is  worthy  of  note 
that  bed-sore  does  not  form  in  some  spinal  diseases  associated  with  muscular" 
atrophy,  as  infantile  paralysis.  This  affection  also  becomes  rapidly  developed 
in  some  cases  of  a^Doplexy  from  intracranial  hsemorrhage  or  partial  softening 
of  the  brain ;  and  in  such  cases  the  bed-sore  does  not  occupy  a  median 
position  in  the  sacral  region,  as  in  cases  of  spinal  origin,  but  forms  towards 
the  centre  of  the  gluteal  region  on  the  paralysed  side.  Chronic  decubitus 
is  found  in  chronic  transverse  myelitis,  in  the  last  stages  of  tabes  dorsalis, 
and  also  in  peripheral  paralysis  caused  by  pressure  on  the  cauda  equina.^ 

Symmetriccd  Gangrene  and  Local  Asphyxia. — This  disease, 
which  was  first  described  by  Raynaud,^  generally  involves  the 
fingers  and  less  frequently  the  toes,  tips  of  the  nose,  and  external 
ear.  The  affected  parts  become  suddenly  white,  cold,  bloodless, 
and  insensible,  while  motor  power  is  diminished.  The  skin  is 
wrinkled  and  shrunken,  and  the  ends  of  the  fingers  appear  thin 
and  conical.  When  the  whole  extremity  is  implicated,  the 
pulse  is  feeble  or  imperceptible.  After  some  months  reaction 
sets  in ;  the  parts  become  congested,  of  a  violet  or  livid  colour, 
intensely  painful,  and  the  seat  of  troublesome  itching ;  vesicles 
form,  which  are  filled  with  a  sero-purulent  fluid,  and,  on  bursting, 
leave  the  cutis  excoriated.  Restoration  of  the  tissues  affected  may 
take  place  even  at  this  stage,  but  the  attack  usually  recurs,  and 
ultimately  the  pants  undergo  a  true  mummification,  followed  by 
a  falling  off  of  a  part  of  the  last  phalanx.  The  disease  is  usually 
met  with  in  chlorotic  and  nervous  individuals,  and  rarely  occurs 
in  children  and  old  persons.  It  appears  to  be  caused  by  a  spastic 
ischsemia  of  the  smallest  arteries. 

Perforating  Ulcer  of  the  Foot. — This  affection  as  seen  in  the 
foot  is  less  like  an  ulcer  than  a  sinus.  It  usually  presents  itself 
as  a  small  aperture,  which  leads  directly  by  a  narrow  channel  to 
exposed  and  diseased  bone.^  From  this  opening  there  is  little  or 
no  discharge ;  the  skin  surrounding  the  orifice  is  greatly  thickened 
by  superimposed  layers  of  epidermis,  and,  indeed,  the  formation 
of  a  large  corn  appears  always  ta  precede  the  destructive  process. 

^  See  Arnozan  (Dr.  X.).  Des  lesions  trophiques  consecutives  aux  maladies  du 
Systeme  nerveux  These,  1880,  p.  149. 

^  Raynaud.  De  I'asphyxie  locale  et  du  la  gangrene  symetrique  des  extremites,  1862. 

^  Savory  and  Butlin.  "  Cases  of  perforating  ulcer  of  the  foot."  Medico-Chirur- 
gical  Transactions,  Vol.  LXII.     Lond.,  1879.    p.  273. 


TROPHONEUROSES.  257 

The  ulcer  is,  as  a  rule,  insensible  to  ordinary  stimuli,  and  there 
is  no  pain  when  the  patient  is  at  rest ;  but  considerable  pain  may 
be  caused  by  pressure  on  the  sole  during  locomotion,  and  the 
patient  often  suffers  from  severe  lightning  pains  in  the  lower 
extremities.  Not  only  are  the  tissues  surrounding  the  wound 
insensible,  but  there  is  also,  as  a  rule,  more  or  less  complete 
cutaneous  anaesthesia  and  analgesia  of  the  whole  of  the  sole  of  the 
foot,  and  there  may  be  loss  of  sensation  in  the  region  of  distribu- 
tion of  one  or  more  of  the  cutaneous  nerves  as  far  up  as  the  calf, 
or  even  as  the  knee.  The  surface  is  usually  very  cold  in  the  anses- 
thetic  area,  the  extremity  is  likewise  apt  to  become  livid  on  slight 
exposure,  and  is  prone  to  attacks  of  erythematous  inflammation, 
or  of  eczema.  These  inflammatory  attacks  sometimes  implicate 
the  subcutaneous  tissues  ;  the  limb  then  becomes  greatly  swollen 
and  oedematous,  and  the  attack  occasionally  terminates  in  sup- 
puration. Lesions  of  the  articulations  of  the  foot  frequently 
accompany  this  affection,  and  not  only  is  the  joint  in  direct 
relation  with  the  wound  diseased,  but  it  is  also  not  uncommon 
to  meet  with  more  or  less  complete  ankylosis  of  all  the  phalan- 
geal, metatarso-phalangeal,  and  tarso-metatarsal  articulations 
(Duplay  and  Morat).  Sub-luxations  of  the  articulations  of  the 
foot,  with  their  consequent  deformities,  sometimes  take  place ; 
these  may  implicate  the  toes  affected  by  ulceration,  or  extend  to 
the  articulations  remote  from  the  ulcers,  or  all  the  joints  of  the 
foot  may  be  affected.  The  nails  assume  a  brownish  colour;  they 
become  greatly  thickened,  curved,  longitudinally  and  laterally, 
furrowed,  dry,  and  cracked.  The  skin  of  the  leg  becomes  at  times 
pigmented,  there  is  an  increase  in  the  growth  of  the  hair ;  and 
the  foot  is  bathed  in  sweat,  which  has  a  peculiarly  foetid  odour. 

The  ulcer  is  generally  situated  over  the  metatarso-phalangeal 
articulations,  most  frequently  over  those  of  the  big  and  little  toes. 
There  may  be  as  many  as  three  ulcers  on  one  foot,  and  when 
both  feet  are  affected  the  disease  is  generally  symmetrical.  The 
affection  has  rarely  been  met  with  in  the  hands.  The  disease  is 
essentially  chronic ;  the  ulcers  may,  under  favourable  circum- 
stances, remain  stationary  for  a  long  time,  and  may  even  heal 
under  prolonged  rest,  but  a  relapse  readily  occurs  when  the 
patient  begins  to  walk. 

The  first  accurate  description  of  this  disease  was  given  by 
VOL.  I.  R 


258  TKOPHONEUROSES. 

Nelaton,^  although  the  affection  was  evidently  referred  to  by 
many  previous  writers.  Soon  afterwards  Vesigni^,^  who  regarded 
the  affection  as  a  kind  of  plantar  psoriasis,  gave  a  detailed  de- 
scription of  it,  and  named  it  "  mal  plantaire  perforant."  In  1855 
Leplat^  gave  an  accurate  account  of  the  origin  and  course  of  the 
affection,  and  maintained  that  the  ulcers  were  caused  by  pressure. 
In  a  case  examined  by  M.  Pean,*  in  1863,  the  vessels  of  the 
foot  were  found  partially  obstructed  by  calcareous  degeneration, 
and  he  consequently  attributed  the  disease  to  arterial  degenera- 
tion. This  opinion  was  supported  by  Delsol,^  Dolbeau,®  and 
others,  but  was  subsequently  contradicted  by  Sidillof^  and 
Guyou,^  who  reported  cases  in  which  the  vessels  were  normal. 
In  1864,  M.  Poncet^  directed  attention  to  the  similarity  between 
the  perforating  ulcers  of  the  foot  and  the  ulcers  occurring  in 
leprous  patients.  Several  years  later  Estlander^*^  endeavoured  to 
prove  that  all  perforating  ulcers  were  due  to  leprosy,  and  were 
to  be  regarded  as  the  last  remnants  of  the  disease  in  countries 
in  which  it  had  formerly  existed.  In  1872,  M.  Poncet,^^  in  tracing 
the  relation  existing  between  leprosy  and  perforating  ulcer,  found 
in  a  case  of  the  latter  disease  that  the  nerves  were  diseased,  the 
connective  tissue  being  thickened,  the  nuclei  multiplied,  and  the 
fibrils  atrophied.  In  the  following  year  Duplay  and  Morat^^ 
subjected  the  affected  parts  in  six  cases  of  perforating  ulcer 
observed  by  them  to  microscopical  examination,  and  found  all  the 
fibrils  of  the  nerves  much  degenerated  as  far  up  as  they  could  be 
examined.  The  authors  thought  that  the  degenerative  lesion  of 
the  nerves  might  be  due  to  various  causes,  such  as  section  and 
compression  of  large  nervous  trunks,  and  disease  of  the  spinal 

*  Nelaton-    "  AfiFection  singuliere  des  os  da  pied."    Gaz.  des  Hop.,  1852,  p.  13. 
^  Vesignie.     Gaz.  des  Hop.,  1852,  p.  58. 

*  Leplat.     "Mal  perforant  du  pied."    Gaz.  des  Hop.,  1855,  p.  465,     These  de 
Paris,  1855. 

•*  Pean.     Gaz.  des  Hop.,  1863,  p.  116. 

*  Delsol.    These  de  Paris,  1864.    Canstatt's  Jahresb.,  Bd,  III.,  1865,  p.  204. 

8  Dolbeau.    Le9on8  de  Clinique  Chirurgicale,  1867,  p.  414. 
^  Sidillot.     Gaz.  des  Hop.,  1865,  p.  497. 

«  Guyon,     Gaz.  des  Hop.,  1869,  p.  413. 

9  Poncet.     Gaz.  Hebdom.,  Ser.  II.,  Tome  IX.,  1872,  p.  51. 
1°  Estlander.    Deutsche  Klinik,  1871,  p.  144. 

"  Poncet.  Me'moires  de  med.  et  de  chir.  militaire,  1864.  Gaz.  Hebd.,  Ser.  II., 
Tome  IX.,  p.  51. 

1==  Duplay  et  Morat.  Arch.  g^n.  de  med.,  VI.  s^rie,  Tome  XXI.,  1873, 
pp.  257,  403,  and  507. 


TROPHONEUROSES,  259 

ganglia  and  spinal  cord.  These  observations  have  since  been 
confirmed  by  Fischer/  Paul  Bruns,^  Savory  and  Butlin,^  and 
others,  so  that  the  nervous  theory  of  the  affection  is  now  placed 
upon  a  secure  basis.  I  am  indebted  to  Mr,  Priestley  for  the 
notes  of  the  following  case  of  perforating  ulcer  and  for  the  oppor- 
tunity of  examining  sections  of  the  affected  nerves : — 

C.  C,  aged  forty-two  years,  has  been  for  several  years  under  the  care  of 
Mr.  Heath.  Twenty  years  ago  he  contracted  syphihs,  but  never  siifFered 
from  any  decided  secondary  or  tertiary  symptoms.  Five  years  ago  an  ulcer 
formed  on  the  sole  of  the  right  foot  beneath  the  metatarsal  bone  of  the 
great  toe.  Necrosed  portions  of  the  bone  were  several  times  removed,  but 
the  ulcer  did  not  heal.  This  foot  was  usually  bathed  in  sweat  of  a  very 
fcetid  odour,  the  sole  was  extremely  sensitive  to  pressure,  and  there 
was  general  cutaneous  hypereesthesia  of  the  right  leg  and  foot,  but 
anaesthesia  was  never  observed.  Towards  the  end  of  last  year  a  round 
u^lcer,  surrounded  by  thickened  epidermis,  formed  on  the  sole  of  the  left 
foot  about  its  middle  and  opposite  the  bases  of  the  metatarsal  bones.  In 
November,  1881,  the  right  foot  was  amputated  by  Syme's  method,  and  the 
wound  healed  slowly,  but  the  stump  has  not  yet  been  freely  used.  The 
posterior  tibial  and  plantar  nerves  were  found  thickened.  The  skin  of  the 
left  leg  and  foot  continued  very  hyperaesthetic,  the  sole  was  extremely  sen- 
sitive to  pressure,  the  reflex  of  the  sole  was  very  lively,  ankle  clonus  could 
be  elicited,  and  the  patellar-tendon  reaction  was  increased.  The  patellar- 
tendon  reaction  of  the  right  leg  is  also  very  lively,  but  it  is  not  known 
whether  ankle  clonus  was  present  before  amputation.  The  ulcer  of  the 
left  foot  proving  intractable  to  treatment,  the  leg  was  amputated  at  the 
middle  of  the  tibia  by  Fergusson's  method,  and  the  stump  healed  rapidly 
and  soundly.  The  posterior  tibial  nerve  near  its  bifurcation  into  the 
plantar  nerves  was  greatly  thickened,  but  it  appeared  of  normal  size  in  the 
stump.  A  microscopical  examination  of  the  thickened  nerve  revealed  a 
remarkable  thickening  of  the  perineurium  and  endoneurium,  with  multi- 
plication of  nuclei.  Many  of  the  nerve  fibres  were  destroyed,  while  others 
were  atrophied. 

But  the  most  remarkable  and  interesting  feature  in  the  patho- 
logy of  perforating  ulcer  of  the  foot  is  its  frequent  association 
with  locomotor  ataxia. 

In  1861,  Demarquay*  drew  attention  to  the  anaesthesia  which 
so  often  accompanies  perforating  ulcer  of  the  foot ;   and  some 

'  Fischer,     Langenbeck's  Archiv.     Bd.  XVIII.  (Biblio.),  1874,  s.  301. 
^  Bruns.    Berl.  klin.  Wochenschr.  (Biblio.),  1875,  p.  417. 

'  Savory  and  Butlin.  Medico-Chir.  Transactions,  Lond.,  1879.  Vol.  LXIL, 
p.  384, 

*  Demarquay,    L'Union  Med,    N.S.,  Tome  X.,  1861,  p.  105, 


260  TEOPHONEUROSES. 

of  the  patients  mentioned  by  Duplay  and  Morat  suffered  from 
shooting  pains  in  the  lower  extremities,  while  strabismus 
and  other  ocular  troubles  have  been  described  as  occurring 
in  such  patients.  It  is  now  found  that  the  subjects  of  per- 
forating ulcer  suffer,  in  addition  to  the  lancinating  pains 
and  anaesthesia  in  the  lower  extremities,  from  gastric  crises, 
arthropathies,  swaying  movements  on  closing  the  eyes,  tottering 
and  unsteady  gait,  and  absence  of  patellar  tendon  reaction.  As 
pointed  out  by  Ball^  and  Fayard,^  perforating  ulcer  appears  to 
be  a  very  early  symptom  of  locomotor  ataxy,  and  may  even 
precede  the  anaesthesia  of  the  lower  extremities.  It  is  gene- 
rally associated  with  the  neuralgic  form  of  ataxia,  and  motor 
troubles  are  not  often  prominent  features  of  such  cases.  This 
accounts  for  the  fact  that  the  connection  between  the  two  affec- 
tions was  not  discovered  at  a  much  earlier  period,  and  it  might 
still  remain  undetected  if  not  for  the  great  value  of  the  patellar 
tendon  reaction  as  a  diagnostic  sign.  A  curious  case  of  perforating 
ulcer  of  the  left  foot  is  reported  by  Ogston,^  in  which  there  were 
anaesthesia  and  slight  congenital  talipes  equino-varus  of  the 
affected  foot,  while  a  puckered  cicatrix  in  the  upper  sacral  and 
lower  lumbar  regions,  under  which  the  spinous  processes  of  the 
vertebrae  could  not  be  felt,  showed  that  the  patient  had  suffered 
from  spina  bifida. 

§  119.  Trophic  Disorders  of  the  Nails  and  Hair. 

After  section  of  the  sciatic  nerve  in  mammalia  the  limb 
becomes  swollen  at  its  extremity,  the  toes  ulcerate,  and  the  nails 
fall  off.  Schroder  van  der  Kolk,  who  first  performed  the  experi- 
ment, attributed  the  nutritive  affection  to  the  loss  of  the  normal 
nervous  action.  Brown-S^quard  repeated  the  experiment  on 
guinea-pigs  and  rabbits,  and  showed  that  no  notable  nutritive 
changes  took  place  in  the  paralysed  limb,  when  the  extremity 
was  prevented  from  coming  in  contact  with  the  hard  ground. 
Traumatic  lesions  of  nerve  trunks  in  man,  in  which  the  nerve  is 
not  completely  divided,  are  not  only  often  followed  by  cutaneous 

'  BalL  Transactions  of  the  International  Medical  Congress,  Vol.  II.  Lond., 
1881.     p.  52. 

^  Tayard.  "  Contribution  du  mal  perforant  dans  I'ataxie  locomotrice  progressive." 
These  de  Paris,  1881. 

^  Ogston.    Lancet,  Vol.  II.,  187G,  p.  13. 


TROPHONEUEOSES.  261 

nutritive  disorders,  but  also  by  various  deformities  of  the  nails 
either  of  the  fingers  or  toes,  according  as  the  nerves  of  the  upper  or 
lower  extremity  are  affected  respectively.  In  such  cases  the  nails 
become  greatly  curved — both  laterally  and  longitudinally — 
furrowed,  dry,  and  cracked  at  their  extremities,  and  of  a  yellowish 
brown  colour.  These  deformities  may  also  occur  in  connection 
with  neuralgic  affections,  and  idiopathic  neuritis  of  sensory  nerve 
trunks.  They  may  likewise  be  found  in  connection  with  acute 
and  chronic  myelitis,  or  as  a  result  of  hemiplegia;  but  in  the 
latter  case  it  is  very  probable,  as  will  hereafter  be  more  fully 
pointed  out,  that  the  spinal  cord  participates  in  the  affection. 

Attention  has  recently  been  drawn  by  MM.  Arloing  and 
Jofifroy^  to  the  fact  that  in  the  course  of  locomotor  ataxy  the 
nails  of  the  great  toes  sometimes  fall  off  spontaneously,  and  are 
then  rapidly  replaced  by  a  new  and  perfectly  normal  nail,  which 
in  its  turn  may  fall  off  some  months  later,  and  that  this  process 
may  occur  in  the  same  nail  several  times  in  succession.  The 
falling  off  of  the  nail  may  be  preceded  for  some  weeks  by  a  dull 
pain,  or  by  a  feeling  of  uneasiness  in  the  toe,  and  then  the  nail 
falls  off  without  being  accompanied  either  by  suppuration,  or  by 
apparent  ulceration  of  the  matrix.  In  other  cases  the  patient 
observes  that  the  nail  of  one  great  toe,  and  a  few  days  later  of 
the  corresponding  toe  of  the  opposite  foot,  has  suddenly  become 
of  a  dark  blue  colour  from  subungual  effusion  of  blood ;  and  a 
few  days  afterwards  the  nail  falls  off,  without  being  preceded  or 
accompanied  by  pain  or  other  warning.  Similar  cases  have  been 
recorded  by  Pitres^  and  Roques.*  Still  more  recently  a  case  is 
recorded  by  M.  Jeffrey*  in  which  the  nail  of  the  great  toe  fell 
off  three  times  in  eighteen  months,  and  in  which  the  symptoms 
were  those  of  sclerosis  in  patches  and  not  of  locomotor  ataxy. 

The  hair  frequently  suffers  from  nutritive  disorders,  subse- 
quent to  lesions  of  the  nervous  system.     Such  disorders  often 

^  Joffroy  (Alix).  "Chute  de  I'ongle  des  gros  orteils  chez  un  malade  atteint 
d'ataxie  locomotrice  progressive."    Archiv.  de  Physiologic,  IX.,  1882,  p.  174. 

^  Pitres.  "  De  la  chute  spontanee  des  ongles  chez  les  ataxique."  Progres  Med., 
1882,  p.  139. 

"  Roques.  "  Chute  spontanee  des  ongles  chez  von  ataxiques."  L'Union  Med., 
1882,  No.  91.    Abstr.  Centralbl.  f.  klin.  Med.,  Bd.  III.,  1882,  No.  20,  p.  319. 

*  Joffroy.  "  Chute  spontanee  de  I'ongle  des  gros  orteils  chez  un  malade  noa 
ataxiques."  L'Union  Medical,  1882,  No.  106.  Abstr.  Centralbl.  f.  klin.  Med  , 
Bd.  III.,  1882,  No.  21,  p.  335. 


262  TROPHONEUROSES. 

occur  after  experimental  injuries  of  nerve  trunks  in  animals. 
After  section  of  the  infraorbital  nerve  in  rabbits  the  long  hair 
of  the  beard  often  falls  out,  while  chemical  irritation  of  the 
sciatic  nerve  in  the  same  animal,  followed  by  ascending  neuritis 
and  myelitis,  is  frequently  associated  with  loss  of  hair  on  the 
posterior  part  of  the  body  (Eulenburg).  Local  affections  of  the 
hair  often  occur  in  man  after  traumatic  lesions  of  nerve  trunks, 
or  in  connection  with  idiopathic  neuritis  and  neuralgia.  The 
hairs  over  the  region  of  distribution  of  a  nerve  affected  with 
neuralgia  have  sometimes  been  observed  to  become  hyper- 
trophied,  and  even  increased  in  number ;  but  as  a  rule  the 
effect  of  neuralgia  upon  the  hair  is  to  make  it  brittle,  and  to 
cause  it  to  fall  out  in  considerable  quantities.  Localised  grey- 
ness  of  the  hair  is  often  associated  with  ophthalmic  neuralgia, 
and  it -may  also  involve  that  of  the  eyebrow  of  the  affected 
side ;  and,  what  is  a  still  more  remarkable  fact,  this  greyness 
often  assumes  an  intermittent  character,  increasing  during,  and 
for  sometime  after,  an  acute  attack  of  pain,  while  a  partial  or 
total  restoration  of  colour  takes  place  in  the  interval  between 
the  paroxysms  (Anstie).  Severe  emotional  disturbance  has  been 
known  to  cause  the  hair  of  the  head  to  turn  grey  suddenly  in  a 
single  night.  After  severe  injuries  of  nerve  trunks,  which  give 
rise  to  nutritive  cutaneous  disorders,  and  especially  to  "glossy 
skin,"  the  hair  completely  disappears  from  the  fingers  affected 
(Weir  Mitchell).  An  increased  growth  of  hair  has  occasionally 
been  observed  after  injuries  of  nerve  trunks,  and  in  chronic 
myelitis. 

§  120.  Cutaneous  Secretory  Affections. 

Nervous  anomalies  in  the  secretion  of  the  skin  may  occur 
both  in  central  and  peripheral  diseases  of  the  nervous  system. 
Various  pathological  facts  appear  to  prove  the  existence  of 
cutaneous  secretory  nerve  fibres  independently  of  the  vaso- 
motor nerves.  Diminution  or  abolition  of  the  secretion  of  sweat 
may  at  times  exist,  especially  in  paralysed  extremities,  side  by 
side  with  the  phenomenon  of  vaso-motor  paralysis,  such  as  local 
increase  of  temperature  and  redness ;  and  conversely,  increased 
secretion  of  sweat  often  exists  on  the  palms  of  the  hands  in 
connection    with    vaso-motor    contraction    and    diminution   of 


TROPHONEUROSES.  263 

temperature.  In  diffused  sweats  caused  by  severe  emotional 
disturbances  the  temperature  is  diminished,  hence  these  are 
called  "  cold  sweats."  The  recent  experiments  of  Luchsinger^ 
show  that  peripheral  irritation  of  the  divided  sciatic  nerve  in 
animals  induces  an  increase  of  sweat  in  the  paralysed  parts. 

The  cutaneous  secretory  neuroses  consist  of  excessive  sweating 
or  hyperidrosis,  diminution  or  absence  of  the  secretion  or  ani- 
drosis  ]  and  changes,  not  in  the  quantity,  but  in  the  quality  of  the 
secretion,  which  may  be  compendiously  grouped  under  the  term 
paridrosis.  The  profuse  sweating  of  acute  disease,  as  intermit- 
tent fever,  that  which  results  from  the  action  of  various  toxic 
agents,  as  opium  and  chloroform,  the  partial  sweats  which  occur 
during  hysterical  and  epileptoid  attacks,  are  all  undoubtedly  of 
nervous  origin.  Still  more  striking  examples  are  to  be  found 
in  the  unilateral  perspirations  which  have  been  described 
under  the  name  of  hyperidrosis  unilatercdis.  This  affec- 
tion is  sometimes  limited  to  one  half  of  the  head,  and  at 
other  times  extends  to  the  arm  of  the  same  side,  or  even 
occupies  the  entire  half  of  the  body,  and  is  usually  associated 
with  severe  nervous  affections,  such  as  hemicrania,  Graves's 
disease,  diabetes  mellitus,  tabes  dorsalis,  and  dementia  paralytica. 
It  is  probably  connected  with  lesion  of  the  sympathetic  or  of  the 
cerebro-spinal  centres  with  which  the  latter  is  united.  Com- 
pression of  the  cervical  sympathetic  by  tumour  gives  rise  to 
cutaneous  redness,  contraction  of  the  pupil,  and  increased  per- 
spiration on  the  same  side  of  the  head  (Ogle^).  Guttmann^ 
has  published  a  case  in  which  unilateral  sweating  of  the  head  was 
associated  not  with  contraction  but  dilatation  of  the  pupil  of  the 
same  side,  along  with  slight  exophthalmos.  Meyer  has  shown 
that  by  galvanisation  of  the  cervical  sympathetic  in  man  an  in- 
creased secretion  of  sweat  as  well  as  a  slight  rise  of  temperature 
may  be  induced  in  the  arm  of  the  same  side.  Nitzelnadel*  has, 
on   the  other  hand,  found  that  in  a  case  of  hyperidrosis  uni- 

^  See  Schwimmer  (E.).  Die  neuropathischen  Dermatonosen.  Wien  und  Leipzig, 
1882.     p.  214. 

^  Ogle.  Lancet,  "Vol.  L,  1869,  p.  461;  and  Medico-Chirurgical  Transactions, 
Vol.  XLI.,  1858,  p.  397. 

*  Eulenburg  and  Guttmann.  Physiology  and  pathology  of  the  sympathetic 
system  of  nerves.     Lond.,  1879.     p.  58. 

*  Nitzelnadel.  "Ueber  nervose  Hyperidrosis  nnd  Anidrosis."  Jena,  1867. 
laaug.  Dissert.     Quoted  by  Eulenburg  and  Guttmann,  Op.  ciL,  p.  57. 


264  TKOPHONEUROSES. 

lateralis  galvanisation  of  the  sympathetic  was  followed  by  diminu- 
tion of  the  secretion.  Some  cases  of  unilateral  hyperidrosis  cannot 
be  explained  on  the  supposition  of  an  affection  of  the  cervical 
sympathetic.  In  a  case  described  by  Pokrofifsky^  a  profuse  per- 
spiration burst  out  over  the  right  half  of  the  face  of  the  patient 
always  during  meals,  which  appears  to  have  been  connected 
with  an  old  parotitis  implicating  the  right  facial  nerve,  and 
leading  to  a  slight  degree  of  asymmetry  of  the  face. 

Anidrosis  is  a  frequent  symptom  of  fevers,  diabetes  mellitus, 
chronic  Bright's  disease,  and  of  certain  skin  diseases.  This  con- 
dition is  also  often  associated  with  many  profound  neuroses,  as 
dementia  paralytica.  The  diminution  of  perspiration,  which  is 
caused  by  various  toxic  agents,  such  as  atropine,  is  evidently  due 
to  action  on  the  nervous  system.  Abnormal  dryness  of  the  skin 
is  also  observed  as  a  local  symptom  in  association  with  other 
nutritive  changes.  A  good  example  of  local  dryness  of  the  skin 
occurs  in  unilateral  atrophy  of  the  face,  and  a  similar  local  con- 
dition may  also  be  found  on  the  extremities  in  the  course  of  the 
most  different  cerebral,  spinal,  and  peripheral  chronic  nervous 
affections. 

Paridroses  of  the  cutaneous  secretion  due  to  nervous  disease 
are  of  various  kinds,  and  no  doubt  further  observations  will 
greatly  add  to  their  number.  In  some  nervous  affections  the 
secretion  manifests  a  peculiar  odour  (Osmidrosis).  The  American 
surgeons^  observed  excessive  sweating,  with  strong  odour  of 
vinegar,  after  severe  contusions  of  peripheral  nerves  ;  and  in  one 
case  the  smell  resembled  that  from  a  bad  drain.  The  secretion 
at  other  times  becomes  changed  to  a  black,  blue,  red,  or  green 
colour  (Chromidrosis).  Coloured  perspiration  occurs  generally 
in  hypochondriacs,  in  women  with  uterine  disorders  of  various 
kinds ;  or  as  the  result  of  grief,  fright,  and  other  emotional  dis- 
turbances. In  some  few  cases  extravasation  of  blood  takes  place 
into  the  sweat  glands,  giving  rise  to  bloody  sweating  or  hcemati- 
drosis.  This  condition  appears  occasionally  to  be  vicarious  of  the 
menstrual  flux  (Hebra),  but  it  is  usually  associated  with  hysteria 
and  other  central  nervous  affections.    It  is  probable  that  in  most 

'  Pokroffsky.     Berlin  klin.  "Wochenschrift,  1875,  p.  164. 

^  S.  "Weir  Mitchell,  Morehouse,  and  Keen.  Gunshot  wounds  and  other  injuries 
of  nerves.     Philad.,  1864.    p.  86. 


TROPHONEUROSES.  265 

of  the  cases  described  as  hgematidrosis  the  colouring  matter  of 
the  blood  alone  escapes.  Mr.  Stocks^  brought  under  the  notice 
of  the  members  of  the  Manchester  Medical  Society,  a  few  weeks 
ago,  the  case  of  a  young  lady,  who  had  for  some  time  suffered 
from  aggravated  hysterical  symptoms,  and  who  for  three  nights 
in  succession  found  her  linen  and  pillow-slip  speckled  with  small 
reddish  spots.  Similar  spots  were  also  found  scattered  over  her 
body  and  head ;  they  were  caused  by  dried  colouring  matter  of 
a  magenta  hue,  which  was  easily  removed.  The  spots  on  the 
pillow-slip,  which  was  exhibited  at  the  meeting,  were  much 
brighter  in  tint  than  an  ordinary  blood-stain. 

§  121.  Theory  of  Cutaneous  Trophic  Affections. — Patholo- 
gical facts  appear  to  warrant  the  inference  that  the  cutaneous 
trophic  and  secretory  fibres  are  distributed  to  the  surface  along 
with  the  sensory  fibres.  The  central  course  of  these  fibres  is  not 
easy  to  determine,  but  they  apparently  pass  through  the  inter- 
vertebral ganglia  and  posterior  roots  to  join  the  posterior  horns 
of  the  grey  matter  of  the  spinal  cord.  The  central  and  posterior 
parts  of  the  grey  substance  of  the  spinal  cord  appear  to  stand  in 
the  same  relation  to  the  nutrition  of  the  skin  that  the  anterior 
horns  of  grey  matter  do  to  the  nutrition  of  the  muscles  and 
joints.  The  central  course  of  the  cutaneous  trophic  fibres  is 
unknown,  but  these  fibres  cannot  be  regarded  as  identical  with 
the  cutaneous  vaso-motor  nerves,  since  the  latter  pass  out  along 
with  the  anterior  roots  to  join  the  sympathetic  through  the  rami 
communicantes,  and  appear  to  pass  through  the  cord  in  the 
antero-lateral  columns. 

That  the  cutaneous  tropliic  fibres  are  associated  with  the  sensory  and 
not  with  the  motor  fibres  of  the  peripheral  nerves  is  shown  by  the  facts  that 
these  nutritive  disturbances  are  almost  always  accompanied  by  severe  pains, 
and  other  forms  of  disordered  sensation  ;  and  that,  when  the  motor  and 
sensory  fibres  are  found  in  separate  nerves,  such  as  the  facial  and  fifth,  the 
nutritive  affections  are  always  caused  by  disease  of  the  sensory  nerves. 
What  part,  if  any,  the  ganglia  of  the  posterior  roots  take  in  the  production 
of  peripheral  nutritive  affections  is  not  known.  The  cutaneous  nutritive 
affections  caused  by  disease  of  the  spinal  cord  are  also  almost  always  accom- 
panied by  severe  sensory  disturbances.  The  cutaneous  eruptions  observed 
in  locomotor  ataxy  always  make  their  appearance  simultaneously  with 

'  See  British  Med.  Journal,  Vol.  II.,  1882,  p.  845. 


266  TROPHONEUROSES. 

j)aroxysms  of  lancinating  j)ains.  The  anatomical  substratum  of  locomotor 
ataxy  is,  as  is  well  known,  sclerosis  of  the  posterior  root-zones  {Fig.  13,  p?*) ; 
and  Charcot  attributes  the  various  sensory  disturbances,  which  accompany 
the  early  stages  of  this  disease,  to  irritation  of  the  internal  radicular 
fasciculus  {Fig.  13,  pr').  Charcot  thinks  that  the  cutaneous  trophic  fibres 
also  pass  through  this  bundle,  and  that  these  fibres  are  consequently  liable 
to  irritation  simultaneously  with  the  other  fibres  which  it  contains. 

The  cutaneous  nutritive  disorders  which  accompany  acute  and  chronic 
myelitis  are,  when  not  resulting  from  implication  of  the  fibres  of  the 
internal  radicular  fasciculus,  due  to  disease  of  the  central  grey  tube.  That 
these  disorders  are  caused  by  disease  of  the  posterior  or  sensory  and  not  of 
the  anterior  or  motor  portion  of  the  grey  substance  is  conclusively  shown 
by  the  facts  that  they  are  entirely  absent  in  infantile  paralysis  and  the 
other  diseases  limited  to  the  anterior  grey  horns  ;  and  that  not  only  are 
they  present  in  diffused  diseases  of  the  grey  substance,  but  also  that  in 
unilateral  affections  of  the  cord  the  acute  bed-sore  forms  not  on  the  para- 
lysed but  on  the  anaesthetic  side.  Very  little  is  known  with  regard  to  the 
connection  of  the  spinal  cutaneous  trophic  centres  with  the  brain.  It  is 
probable  that  some  of  the  minor  cutaneous  eruptions  which  occur  in 
cerebral  disease  may  be  due  to  vaso-motor  irritation,  while  some  of  the 
severer  affections  are  caused  by  a  simultaneous  affection  of  the  spinal  cord, 
or  of  a  peripheral  nerve.  After  deducting  these,  however,  a  considerable 
number  of  cases  remain  unaccounted  for,  and  it  must  therefore  be  sup- 
posed that  the  spinal  cutaneous  trophic  centres  are  represented  by  a  higher 
centre  in  the  brain,  but  whether  it  is  situated  in  the  medulla  oblongata,  or 
pons,  or  in  the  cortex  of  the  brain,  is  not  known. 

The  next  question  to  be  determined  is  whether  the  cutaneoiis  nutritive 
disorders  depend  upon  paralysis  or  irritation  of  the  trophic  fibres  and  their 
continuation  through  the  cord  and  brain.  The  careful  observations  of 
Weir  Mitchell,  Morehou.se,  and  Keen,  of  those  who  suffered  from  wounds 
and  other  injm"ies  of  the  nerves  during  the  American  war,  appear  to  favour 
the  opinion  that  cutaneous  trophic  disorders  supervene  in  those  cases  in 
which  nerves  suffer  partial  injury  without  being  completely  severed  from 
their  nerve  centres.  These  disturbances  arise  while  the  woxmd  is  healing  ; 
they  are  often  related  to  an  attack  of  inflammation  in  or  about  the  woimd, 
and  are  usually  associated  with  neuralgic  and  paralgic  phenomena,  and 
rarely  with  complete  anaesthesia  and  paralysis.  It  must  also  be  remem- 
bered that  after  gim-shot  wounds  and  other  severe  injuries  of  nerves  the 
trophic  disorders  may  appear  above  the  level  of  the  wound  as  well  as 
below  it. 

The  nutritive  disorders  which  accompany  disease  of  the  spinal  cord 
also  appear  to  favour  the  theory  of  an  irritative  rather  than  a  paralytic 
lesion.  The  cutaneous  eruptions  which  occur  in  the  course  of  locomotor 
ataxy  are  associated  with  severe  paroxysms  of  lancinating  pains  ;  while 
acute  bed-sore  is  associated  with  traumatic  injuries  of  the  cord,  acute 
central  myelitis,  and  hsematomyelia  ;  aU  of  them  being  affections  in  which 


TROPHONEUROSES.  267 

the  paralytic  phenomena  are  likely  to  have  been  preceded  by  symptoms 
of  irritation.  It  has  also  been  pointed  out  by  Charcot  that  many  of 
the  symptoms  which  accompany  the  formation  of  acute  bed-sore  are  indi- 
cative of  irritation,  rather  than  paralysis.  The  most  usual  of  these  symp- 
toms are  priai^ism,  clonic  convidsions  in  the  paralysed  limbs,  and  tonic 
con\'Tilsions  coming  on  in  paroxysms,  while  anaesthesia  of  the  paralysed 
parts  is  by  no  means  constant.  Post-mortem  examination  also  reveals  in 
these  cases  the  presence  of  purulent  infiltration  and  other  evidences  of  an 
inflammatory  process.  It  is  not  improbable,  however,  that  chronic  decu- 
bitus may  be  caused  by  paralysis,  as  well  as  irritation  of  trophic  centres 
or  fibres,  inasmuch  as  it  appears  in  the  terminal  x^eriods  of  chronic  spinal 
affections,  and  has  then  the  characteristics  of  a  passive  rather  than  an 
active  process.  In  a  case  of  transverse  myelitis  from  disease  of  the  verte- 
bral column,  imder  my  care,  the  formation  of  a  chronic  bed-sore  was 
jpreceded  by  complete  ansesthesia  of  the  inferior  extremities,  and  of  the 
sacro-gluteal  region.  This,  however,  only  shows  that  centripetal  conduction 
through  the  cord  was  interrupted  at  the  seat  of  the  disease — the  middle 
dorsal  region — while  it  is  quite  possible  that  the  cutaneous  spinal  trophic 
centres  of  the  gluteal  region  were  in  a  state  of  invitation.  The  case,  there- 
fore, affords  no  trustworthy  evidence  in  either  direction. 

(IV.)-NUTRITIVE    AFFECTIONS   OF   THE  JOINTS,   BONES,    AND 

TEETH. 

Articular  and  Osseous  Trophoneuroses. 

Pathological  facts  appear  to  show  that  the  trophic  fibres  of  the 
bones  and  joints  are  found  in  the  mixed  nerve  trunks,  and  that 
these  issue  along  with  the  motor  fibres  from  the  anterior  cornua, 
where  they  are,  like  the  muscular  trophic  fibres,  connected  with 
a  group  of  large  caudate  cells.  It  is  impossible  to  say  at  present 
in  what  way  these  trophic  fibres  and  cells  are  connected  with 
the  brain,  but  some  connection  doubtless  exists. 

§  122.  Affections  of  Peripheral  Origin. — Affections  of  the 
joints  are  very  frequent  in  connection  with  traumatic  injuries  of 
nerve  trunks  in  which  the  nerves  are  not  completely  divided. 
The  nutritive  affection  of  the  joints  may  occur  at  any  time 
subsequent  to  the  first  few  days  after  the  injury  to  the  nerve, 
and  consists  of  a  painful  swelling,  similar  to  that  which  occurs 
in  subacute  articular  rheumatism.  This  swelling  may  attack 
any  or  all  of  the  articulations  of  a  limb ;  it  often  begins  in 
joints  remote  from  the  seat  of  injury,  and  cannot  therefore  be 
caused  by  direct  extension  of  inflammation  from  the  wound. 


268  TROPHONEUROSES. 

After  the  acute  stage  the  tissues  about  the  articulations  become 
hard,  and  partial  anchylosis  results,  which  may  ultimately  destroy 
the  mobility  of  the  joint.^  Fischer^  succeeded  in  producing  ex- 
perimentally in  animals  diseases  of  the  joints,  similar  to  those 
observed  in  man,  as  the  result  of  disease  of  the  nerves.  Swelling 
and  thickening  of  the  bones  may  occur  as  the  result  of  injuries 
to  nerves,  and  this  may  be  followed  at  a  later  period,  in  young 
people,  by  decided  arrest  of  the  growth  of  the  bone.^  These 
nerve  lesions  may  also  be  followed  by  periostitis  and  subse- 
quent necrosis.*  In  progressive  cases  of  unilateral  atrophy  of 
the  face,  the  bones  of  the  face  participate  to  some  extent  in  the 
wasting. 

§  123.  Afections  of  Spinal  Origin. — Attention  has  been 
directed  by  Charcot^  and  his  scholars  to  the  great  frequency  with 
which  nutritive  changes  occur  in  joints  in  central  diseases  of  the 
nervous  system.  These  affections  may  be  subdivided  into  two 
kinds — those  which  run  an  acute  or  subacute  course,  and  those 
which  assume  a  chronic  form.  The  first  variety  is  accompanied 
at  times  by  more  or  less  severe  pain,  and  tumefaction  and  red- 
ness may  be  so  marked  that  the  joint  affection  simulates  acute 
rheumatism.  The  acute  form  occurs  in  connection  with  Pott's 
curvature,^  traumatic  lesions  of  the  cord,^  and  idiopathic  mye- 
litis.^ The  influence  of  infantile  paralysis  on  the  nutrition  of 
the  bones  of  the  affected  limb  is  well  known,  the  bones  of  the 
diseased  extremity  being  often  thinner  and  shorter  than  those  of 

'  Mitchell,  Morehouse,  and  Keen.  Gunshot  wounds  and  other  injuries  of  nerves. 
Philad.,  1884.    p.  84. 

*  Fischer.  "  Ueber  trophischen  Storungen  nach  Nervenverletzungen  an  den 
Extremitaten."    Berl.  klin.  Wochenschr.,  Bd.  VIII.,  1871,  p.  145. 

^  Blum.  Des  arthropathies  d'origine  nerveuse.  These  de  Paris,  1875.  See  Ogle 
(W.).  Regarding  certain  influences  exercised  by  the  nervous  system  upon  bones. 
St.  George's  Hospital  Reports,  Vol.  VI.,  1871-2,  p.  274. 

•*  Charcot,     Diseases  of  the  ISTerv.  System.     New  Syd.  See,  1877,  pp.  24  and  30. 

*  Charcot  (J.  M.).  "  Sur  quelques  arthropathies  que  paraissent  dependre  d'une 
lesion  du  cerveau  et  de  la  moelle  ^piniere."  Arch,  de  Physiol.,  1868,  p.  160,  et  ibid., 
1869,  p.  121.  BalL  "Des  arthropathies  consecutives  a  I'ataxie  locomotrice  pro- 
gressive."   Gaz.  des  H6p.,  1868,  pp.  506  et  522. 

*  Mitchell  (J.  K.).  American  Journal  of  the  Medical  Soiences.  Philad._,  1831. 
p.  55.  See  also  Mitchell  (S.  Weir).  American  Journal  of  the  Medical  Sciences. 
PhUad.,  1875,  April. 

'  Vigues.    Journal  de  Physiologie,  1863,  p.  130. 

^  Gull.  "  Cases  of  paraplegia."  Guy's  Hospital  Reports,  1858,  3rd  series,  p.  206. 
Mitchell  (J.  K.).  American  Journal  of  the  Medical  Sciences.  Philad.,  1833. 
p.  336. 


TROPHONEUROSES.  269 

the  healthy  limb.*    Articular  affections  have  also  been  observed 
in  progressive  muscular  atrophy^  and  in  disseminated  sclerosis.^ 

The  Chronic  Form  of  articular  disease  due  to  lesion  of  the 
nervous  system  was  first  accurately  described  by  Charcot,  and 
it  is  especially  observed  in  connection  with  locomotor  ataxia. 
The  deformities  of  the  joints  produced  by  this  affection  usually 
occur  in  the  large  joints  of  the  extremities,  such  as  the 
knee,  hip,  shoulder,  and  elbow  joints,  although  the  joints  of 
the  fingers  and  toes  are  occasionally  attacked.*  The  affection 
usually  begins  about  the  same  time  as  the  symptoms  of  motor 
inco-ordination,  and  its  onset  is  accompanied  or  preceded  by 
severe  paroxysms  of  lancinating  pains.  The  symptoms  begin 
suddenly  in  the  absence  of  any  appreciable  external  cause, 
generally  without  any  pain  or  febrile  reaction,  and  the  joint  may 
be  enormously  swelled  within  twenty-four  hours  from  the  com- 
mencement of  the  affection.  The  general  tumefaction  dis- 
appears after  a  few  days,  but  a  more  or  less  considerable  swelling 
remains,  due  to  the  accumulation  of  serous  fluid  in  the  joint, 
and  in  the  periarticular  serous  bursse.  One  or  two  weeks  after 
the  invasion,  the  fluid  disappears  from  the  joint.  In  the  benign 
form  of  the  affection  a  complete  cure  may  be  obtained ;  but  in 
the  malignant  form  the  articular  surfaces  become  greatly 
altered  and  roughened,  so  that  cracking  sounds  are  heard  on 
movement.  After  a  time  the  heads  of  the  bones  become  atro- 
phied and  worn,  the  ligaments  become  relaxed,  and  the  sur- 
rounding muscles  atrophied  and  enfeebled,  so  that  the  joint 
assumes  undue  mobility,  and  spontaneous  luxations  occur. 
It  was  considered  probable  by  Charcot  that  these  arthropathies 
are  caused  by  disease  of  a  certain  group  of  the  large  ganglion 
cells  of  the  anterior  horns.  In  three  cases  examined  by  Charcot 
and  Joffroy  the  anterior  horns  of  grey  matter  were  found 
remarkably  atrophied,  and  a  considerable  number  of  the  large 

^  Humphrey  (G.  M  ).  "  On  the  influence  of  paralysis,  &c.,  upon  the  growth  of 
the  bones."     Med.  Chir.  Transactions,  Vol.  XLV.,  1862,  p.  283. 

*  Remak.  "  Ueber  der  Einfluss  der  Centralorgame  des  Nervensystems  auf 
Krankheiten  der  Knocker  und  der  Gelenke."  Allgem.  med.  Central-Zeitung. 
Berl.,  1863.  p.  154.  Rosenthal.  Treatise  on  the  diseases  of  the  nervous  system. 
New  York,  1879.    p.  286. 

'  Bourneville  et  Gu^rard.  De  la  sclerose  en  plaques  dissemin&es.  Paris,  1869. 
p.  83. 

*Westphal.  Berl.  klin.  Wochenschr.,  1881,  p.  41.'5.  See  also  Page.  Transactions 
of  the  International  Medical  Congress.     Vol.  I.,  1881,  p.  124. 


270  TROPHONEUEOSES. 

gaDglion  cells,  especially  of  the  postero-lateral  group,  were 
atrophied  or  completely  destroyed.  In  unilateral  articular  affec- 
tions of  this  kind  these  changes  were  observed  only  on  the 
corresponding  side  of  the  cord,  and  when  the  shoulder  joint  was 
exclusively  affected  the  disease  was  found  only  in  the  cervical 
region,  and  when  the  knee  joint  was  alone  implicated  the  disease 
was  found  limited  to  the  lumbar  portion  of  the  cord.  This 
opinion,  however,  is  rendered  doubtful  from  the  fact  that  in  three 
more  recent  autopsies  it  was  impossible  to  find  any  alteration  of 
the  cells  of  the  anterior  horns.^  The  frequent  association  of 
gastric  and  laryngeal  crises  with  arthropathies  has  led  Buzzard^ 
to  suggest  that  a  trophic  centre  for  the  osseous  and  articulatory 
system  exists  in  the  medulla  in  the  neighbourhood  of  the  roots 
of  the  vagi,  lesion  of  which  causes  the  affections  of  the  joints 
and  bones ;  but  this  hypothesis  does  not  appear  to  have  a  very 
trustworthy  foundation.  It  is  unnecessary  to  describe  these 
affections  more  minutely,  inasmuch  as  they  will  come  under 
further  consideration  in  the  special  part  of  the  work. 

Fractures. — Spontaneous  fractures  have  attracted  the  atten- 
tion of  surgeons  from  a  remote  period,  but  these  accidents  were 
attributed  to  the  influence  of  certain  diatheses,  such  as  gout, 
rheumatism,  scrofula,  and  cancer.  Larrey^  drew  special  attention 
to  the  fact  that  a  certain  form  of  paralysis  of  the  lower  extre- 
mities was  associated  with  a  strong  predisposition  to  fractures  of 
their  bones.  In  the  record  of  this  case,  however,  it  is  mentioned 
that  the  so-called  paralytic  symptoms  were  associated  with 
amaurosis  and  great  exaltation  of  the  sensibility  of  the  lower 
extremities,  which  renders  it  almost  certain  that  the  symptoms 
were  not  due  to  paralysis,  but  to  ataxia.  In  1873  Weir  Mitchell* 
drew  attention  to  the  frequency  of  spontaneous  fractures  in 
locomotor  ataxia,  and  suggested  that  during  the  progress  of  the 
disease  the  bones  had  undergone  nutritive  changes  which  greatly 
diminished    their   resistance.     This   subject   was   subsequently 

'See  Talamon  (Ch.).  "Dea  lesions  osseuses  et  articulaires  li^es  aux  maladies 
du  svsteme  nerveux."  Kevue  Meusuelle  de  med.  et  de  chir.,  Tome  II.,  1878, 
p.  697. 

=  Buzzard.  Clinical  lectures  on  diseases  of  the  nervous  system.  Lond.,  1882, 
p.  254. 

^  Talamon.     Op.  cit ,  p.  691. 

*  Mitchell.  "  Rest  in  locomotor  ataxia."  American  Journal  of  Medical  Science, 
N.  S.,  Vol.  LXVI.,  1873,  p.  113. 


TROPHONEUROSES.  271 

investigated  by  Charcot^  and  his  followers,  with  their  usual 
thoroughness  and  success.  The  period  of  fracture  is  generally 
preceded  by  two  or  three  paroxysms  of  lancinating  pain  of 
unusual  severity;  at  the  same  time  the  limb  is  found  swollen, 
and  presenting  all  the  symptoms  of  osteo- periostitis,  while 
fracture  occurs  on  the  slightest  movement  of  the  limb,  or  in  the 
entire  absence  of  any  movement  or  other  external  cause.  The 
femur  is  more  frequently  fractured  than  any  other  bone,  the  seat 
of  fracture  being  frequently  the  neck  ;  but  the  boaes  of  the  leg, 
arm,  forearm,  and  indeed  almost  every  bone  of  the  limbs  and 
trunk,  including  those  of  the  vertebral  column,  have  been  found 
fractured.  Multiple  fractures  in  the  same  patient  are  by  no 
means  uncommon,  and  in  one  of  the  cases  published  by  Charcot, 
the  patient,  towards  the  close  of  life,  could  scarcely  move  in  bed 
without  fracturing  some  one  or  other  of  the  few  bones  which 
had  not  already  been  fractured.  Damaschino^  has  drawn  atten- 
tion to  the  fact  that  the  spontaneous  fractures  of  ataxics  reunite 
very  readily  and  rapidly  with  an  enormous  formation  of  callus. 

From  a  careful  chemical  analysis  of  the  affected  bones  in 
locomotor  ataxia,  Regnard^  found  that  the  inorganic  constituents 
only  formed  24  instead  of  66  per  cent,  and  the  organic  76  instead 
of  33  per  cent  of  the  weight  as  in  health.  The  loss  of  the  earthy 
constituents  depended  upon  a  diminution  of  the  phosphates, 
which  were  only  10  instead  of  50  per  cent,  and  the  excess  of  the 
organic  constituents  was  caused  by  an  enormous  increase  of  fat, 
which  formed  37  per  cent  of  the  weight,  while  very  little  fat  is 
found  in  healthy  bones  freed  from  medulla. 

§  124.  Osseous  Affections  of  Cerebral  Origin. — In  the  spastic 
hemiplegia  of  infancy  the  bones  on  the4)aralysed  side  of  the  body 
are  arrested  in  their  development,  and  are  consequently  smaller 
and  shorter  than  the  corresponding  bones  of  the  opposite  side. 
Several  cases  of  this  kind  have  been  recorded  by  myself.*  The 
arthropathies  of  hemiplegic  patients,  which  were  first  described  by 

'  Charcot.  "  Luxations  pathologiques  et  fractures  spontanees  multiples  chez 
une  femme  atteinte  d'ataxie."    Archiv.  de  Physiol.,  Serie  II.,  Tome  I.,  187-4,  p.  166. 

*  Damaschino.     Bull,  de  la  See.  Anat.,  1873-7.5. 

^  See  Bruns  (P.).  "  Spontanfracturen  bei  Tabes,"  Berl.  klin.  Wocbenschr. 
(Biblio.),  1882,  p.  165. 

"  Ross  (J.).  "  On  the  spasmodic  paralyses  of  infancy."  Brain,  Vol.  IV.,  1SS2 
p.  344. 


272  TEOPHONEUROSES, 

Scott  Alison/  Brown-Sdquard,  and  Charcot,-  are  of  the  same  kind 
as  the  acute  arthropathies  of  spinal  origin.  Cerebral  arthropathies 
have  been,  observed  in  connection  with  softening,  haemorrhage, 
and  intracranial  tumours,  but  they  are  more  frequently  asso- 
ciated with  softening  than  either  of  the  other  lesions.  This 
articular  affection  usually  attacks  the  joints  of  the  hand  or  foot, 
and  only  very  rarely  the  elbow  or  knee  joint.  The  affection 
begins  with  a  slight  swelling  and  local  increase  of  temperature, 
either  with  or  without  pain  in  the  joint;  and  at  times  the  tume- 
faction and  redness  are  so  marked  as  to  resemble  the  articular 
affections  of  acute  rheumatism.  The  sheaths  of  the  tendons  are 
sometimes  affected  along  with  the  joints.  These  arthropathies 
occur  usually  at  the  time  late  rigidity  sets  in,  or  from  fifteen  days 
to  a  month  after  the  attack  of  apoplexy.  They  may,  however, 
appear  at  a  much  later  period ;  while  Weir  Mitchell,  on  the  other 
hand,  observed  in  one  case  arthritis  three  days  after  an  attack  of 
apoplexy,  and  in  a  second  case  the  joint  affection  showed  itself 
the  day  following  the  cerebral  attack.  The  nature  of  the  affec- 
tion was  shown  by  Charcot  to  be  a  true  synovitis  with  multipli- 
cation of  the  nuclear  and  fibroid  elements  of  the  articular  serous 
membrane.  In  severe  cases  a  sero-fibrinous  fluid  mixed  with 
white  blood  corpuscles  is  exuded,  which  may  be  sufficiently 
abundant  to  distend  the  synovial  cavity.  The  tendinous  synovial 
sheaths  in  the  neighbourhood  of  the  affected  joints  participate  in 
the  inflammation. 

The  frequent  coincidence  in  time  of  the  appearance  of  these 
arthropathies  and  of  late  rigidity  would  appear  to  indicate  that 
the  former  are  due  to  descending  changes  in  the  pyramidal  tract 
and  probably  also  secondary  implication  of  the  ganglion  cells  of 
the  anterior  cornua  of  the  spinal  cord ;  but  in  two  cases  observed 
by  Charcot  the  autopsies  showed  complete  absence  of  every 
change  in  the  nerves  and  spinal  cord,  and  of  secondary  descending 
sclerosis  of  the  lateral  columns,  Hitzigr^  thinks  that  the  arthritis 
is  of  traumatic  origin  and  due  to  the  displacement  of  the  surfaces 

1  Alison  (Scott).  "Arthritis  occurring  in  the  course  of  paralysis."  Lancet,  1846. 
Vol.  I.,  p.  278. 

*  Charcot.  Arch,  de  Physiol.,  1868,  p.  396;  and  Dis.  Nerv.  Syst.,  Syd.  Soc, 
1877,  p.  93. 

^  Hitzig.  "  TJeber  eine,  bei  schweren  Hemiplegien  auftretende  Gelenkafec- 
tionen."    Virchow's  Archiv.,  Vol.  XLVIII.,  1870,  p.  345. 


TROPHONEUKOSES.  273 

of  the  joints,  caused  by  paralysis  of  the  muscles  surrounding 
them.  This  explanation  may  suffice  for  the  arthropathies  which 
occur  long  after  the  paralysis  has  become  established ;  but  it 
will  not  account  for  the  joint  affections  occurring  a  few  days  after 
the  attack.  Scott  Alison  attributed  the  arthritis  to  diminution 
of  the  vitality  of  the  affected  parts,  permitting  the  previously 
existing  poison  of  the  uric  acid  diathesis  to  act  on  the  joints  of 
the  paralysed  limbs.  Charcot  also  appears  to  incline  towards 
this  theory,  and  adduces  in  its  favour  the  observation  that,  at  an 
autopsy  of  a  hemiplegic  patient,  deposits  of  urate  of  soda  were 
found  in  the  joints,  which  during  life  had  frequently  been  the 
seat  of  pain  and  swelling,  while  nothing  of  the  kind  was  observed 
in  those  of  the  opposite  side. 

§  125.  Osseous  Lesions  in  the  Insane. — Attention  has  of 
recent  years  been  directed,  especially  in  England,  to  the  very 
important  morbid  changes  of  the  osseous  system  which  occur 
amongst  the  insane.  These  affections  are  of  two  kinds,  although 
they  are  probably  fundamentally  the  same.  In  one  of  them  the 
bones  become  so  soft  that  they  yield  readily  to  pressure  and  thus 
produce  various  deformities.  In  the  other  form  the  bones  become 
so  fragile  that  they  are  found  after  death  to  crumble  under  the 
finger  and  thumb,  and  are,  of  course,  during  life  liable  to  fracture. 
The  first  case  of  spontaneous  fracture  in  the  insane  was  published 
by  Davey^  in  1842,  who  at  a  post-mortem  examination  found 
evidences  of  six  fractures  of  the  long  bones.  Cases  in  which  the 
ribs  were  found  at  the  autopsy  so  brittle  that  fracture  could  be 
readily  produced,  or  in  which  evidences  af  fractures  of  the  ribs 
were  actually  found,  have  been  recorded  by  Dickson,^  Pedler,* 
Williams,*  and  others.  Out  of  100  post-mortem  inspections  of 
the  insane  made  by  Gudden,^  evidences  of  fracture  were  found 
in  16  cases,  chiefly  men  who  had  suffered  from  general  paralysis. 
In  three-fourths  of  these  cases  there  were  multiple  fractures ;  in 

»  Davey.  "  Important  case  of  mollities  ossium."  Communicated  by  Mr.  S. 
Solly.     Med.  Times,  1842.     Vol.  VII.,  p.  195. 

*  Dicksou.     Transact,  of  the  Pathological  Soc.  of  London,  Vol.  XXI. 

^  Pedler.  "  Mollities  ossium  and  allied  diseases."  West  Riding  Lunatic  Asylum 
Reports,  Vol.  I.,  1871,  p.  164. 

•*  Williams.     "  On  fractured  ribs  in  the  insane."    Lancet,  Vol.  II.,  1870,  p.  323. 

*  Gudden.  "  Ueber  die  Kippenbriiche  bei  Geisteskranken."  Arch,  f .  Psychiat., 
1870.     Vol.  II.,  p.  682. 

VOL.  I.  S 


274  TROPHONEUROSES. 

one  case  as  many  as  14,  in  another  23,  and  in  another  36  fractures 
were  found.  In  a  case  of  dementia  reported  by  Mercer,^  the 
manubrium  sterni  was  fractured  across  its  middle,  and  the  bone 
was  soft  and  boggy,  so  that  a  knife  could  be  readily  thrust  into 
it ;  the  bones  of  the  skull  were  also  soft,  and  readily  cut  with 
the  knife.  Spontaneous  fractures  of  the  humerus  have  been 
observed  by  Bonnet^  and  Moore,^  of  the  femur  by  Lahr,*  while 
Deas®  met  with  such  fractures  in  both  humerus  and  femur. 
The  morbid  changes  which  occur  in  the  bones  of  the  insane  are 
closely  related  to  those  observed  in  the  spontaneous  fractures  of 
locomotor  ataxia. 

§  126.  Trophic  Affections  of  the  Teeth. — The  teeth  are  not  very 
liable  to  undergo  changes  in  diseases  of  the  nervous  system.  They 
have  been  known  to  fall  out  after  an  attack  of  herpes  affecting 
the  maxillary  branches  of  the  fifth  nerve,®  probably  caused  more 
by  necrosis  of  the  bone  than  by  disease  of  the  teeth  themselves. 
Vallin^  has  directed  attention  to  the  fact  that  the  teeth  sometimes 
fall  out  in  locomotor  ataxia  without  being  attended  by  pain  or 
caries  of  the  bone.  Two  cases  of  this  kind  have  recently  been 
described  by  Demange  f  the  teeth  all  fell  out  within  a  period  of 
a  few  weeks,  and  sclerosis  of  the  posterior  columns  of  the  cord 
was  subsequently  proved  by  post-mortem  examination. 


(V.)— NUTRITIVE    AND    SECRETORY   AFFECTIONS    OF   THE 
GLANDULAR   APPARATUS. 

It  was  shown  by  Pfliiger^  that  the  nerves  of  the  submaxillary 
gland  terminate  in  fine  threads,  which  are  connected  with  and 
terminate  in  the  secretory  cells  of  the  gland,  and  it  is  very  pro- 

»  Mercer.    British  Medical  Journal.    Vol.  I.,  1874,  p.  540. 

2  Bonnet.     Gaz  des  H6p.,  1876,  p.  939. 

»  Moore.     St.  George's  Hospital  Reports,  Vol.  V.,  1871-2,  p.  57. 

*  Lahr.    Allg.  Zeitschr.  f.  Psychiat.,  1880.     Bd.  XXXVII,,  p.  72. 

*  Deas.  "  Notes  on  a  case  of  spontaneous  fracture  of  the  humerus  and  femur, 
&c."    British  Medical  Journal,  VoL  II.,  1877,  p.  9. 

*  Arnozan.  "  Des  lesions  trophiques  cons^cutives  aux  maladies  du  systeme  ner- 
veux."    These,  Paris,  1880.    p.  158. 

'  Vallin.     "Atrophic  des  maxillaires  chez  les  ataxiques."    Union  M^d.,  1879. 

*  Demange  (Prof.).  "  Chute  spontanee  des  dents  et  crises  gastriques  et  laryng^eg 
chez  les  ataxiques.  Lesions  Anatomiques."  Revue  de  Medecine.  Mars,  1882. 
Neurologische  Centralbl.,  1882,  p.  183. 

»  Pfliiger.    Arch.  f.  Microscop.  Anat.,  1869,  p.  193. 


TROPHONEUROSES.  275 

bable  that  the  secretory  nerves  of  other  glandular  organs  have  a 
similar  termination.  With  respect  to  the  lachrymal  gland,  Boll 
has  observed  fine  terminal  threads  distributed  between  the  cells 
of  the  gland.  The  various  experimental  and  pathological  facts 
which  have  been  collected  show  that  the  secretory  nerves  are 
quite  independent  of  the  vaso-motor  nerves  of  these  organs,  and 
that  not  merely  the  secretion  but  even  the  development  of  the 
glands  is  under  the  influence  of  these  nerves  (Heidenhain). 

§  127.  Trophoneuroses  of  the  Salivary  Glands. — Secretory 
disturbances  of  the  large  salivary  glands  may  occur  in  connection 
with  lesions  of  the  peripheral  fibres  of  the  trigeminus,  of  the 
facial  nerve,  or  of  the  cervical  sympathetic.  In  trigeminal 
neuralgia  an  increased  secretion  of  saliva  is  not  an  unfrequent 
symptom,  due  to  reflex  irritation  conveyed  through  the  lingual 
nerve  of  the  fifth  as  the  afferent,  and  the  chorda  tympani  as  the 
efferent  channel.  Stimulation  of  the  glosso-pharyngeal  is  even 
more  effectual  in  increasing  the  flow  of  saliva  than  stimulation 
of  the  lingual  nerve.  If  the  chorda  tympani  be  divided  the 
flow  of  saliva  from  the  submaxillary  gland  is  arrested  from  want 
of  efferent  impulses  ;  but  if  the  peripheral  portion  of  the  nerve 
be  stimulated  a  copious  secretion  of  a  thin  watery  saliva  at  once 
takes  place,  while  the  arteries  of  the  gland  become  dilated. 
That  the  increased  secretion  does  not  depend  upon  the  vaso- 
motor action  of  the  stimulated  nerve  is  shown  by  the  fact  that 
when  the  chorda  tympani  is  energetically  stimulated  the  pres- 
sure acquired  by  the  saliva  in  the  duct  exceeds  for  the  time  the 
arterial  blood-pressure. 

In  peripheral  paralysis  of  the  facial  nerve  there  is  often  a 
diminution  of  secretion  of  saliva  on  the  paralysed  side.  This  is 
due  to  the  fact  that  the  chorda  tympani  contains  the  secretory 
fibres  for  both  the  submaxillary  and  sublingual  glands ;  while 
the  secretory  fibres  of  the  parotid  are  contained  in  the  small 
superficial  petrosal  nerve.  In  paralysis  of  the  cervical  sympa- 
thetic a  diminution  of  salivary  secretion  may  be  observed  on 
the  affected  side,  inasmuch  as  the  parotid  obtains  a  portion 
of  its  secretory  fibres  through  the  cervical  sympathetic.  Certain 
poisons,  as  atropine,  paralyse  the  secretory  fibres  of  the  chorda 
tympani,    and    consequently   lead    to    a    diminution   or   arrest 


276  TROPHONEUROSES. 

of  the  salivary  secretion ;  other  substances,  as  digitalin,  physo- 
stigmin,  nice  tin,  and,  before  all,  jaborandi,  appear  to  increase 
the  action  of  the  salivary  secretory  fibres  and  lead  to  an  increased 
flow  of  saliva. 

The  secretion  of  saliva  may  be  influenced  by  direct  or  reflex 
action  on  the  intracerebral  secretory  paths.  Bernard  found  that 
an  increased  flow  of  saliva  might  be  produced  by  puncture  of  the 
floor  of  the  fourth  ventricle  behind  the  origin  of  the  trigeminus. 
It  is  possible  that  the  increased  flow  of  saliva  observed  in  bulbar 
paralysis  may  at  times  be  due  to  irritation  of  this  point.  An 
enormously  increased  flow  of  saliva  has  been  observed  by 
Eulenburg  in  dogs  after  destruction  by  the  actual  cautery  of 
portions  of  the  cortex  of  the  brain  lying  in  front  of  the  cruciate 
sulcus.  The  saliva  flowed  out  in  a  constant  stream  from  the 
angle  of  the  mouth  on  the  opposide  side  to  the  injured  hemi- 
sphere, and  was  of  the  same  thin  watery  character  which  is 
observed  after  irritation  of  the  chorda  tympani. 

§  128.  Trophoneuroses  of  the  Lachrymal  Glands. — Increased 
lachrymal  secretion,  like  increased  salivary  secretion,  often  occurs 
in  trigeminal  neuralgia,  more  especially  of  the  two  first  divi- 
sions. It  is  caused  both  by  direct  and  reflex  irritation  of 
the  secretory  nerves,  which,  according  to  the  experiments  of 
Herzenstein^  and  Wolferz,  are  partly  contained  in  the  lachrymal 
nerve  and  partly  in  the  subcutaneous  malar  nerve.  Electrical 
irritation  of  these  nerves  caused  increased  secretion  of  tears  on 
the  side  of  the  irritation ;  and  the  same  result  can  be  induced  in 
a  reflex  manner  by  peripheral  irritation  of  the  first  and  second 
divisions  of  the  trigeminus.  Irritation  of  the  branches  of  the 
trigeminus  may  also  give  rise  to  an  increased  secretion  of  a 
watery,  mucous,  or  even  bloody  fluid  from  the  mucous  membrane 
of  the  nose,  which  may  also  be  caused  by  irritation  of  the 
spheno-palatine  ganglion,  and  of  the  nerve  branches  which 
spring  from  it. 

The  diminislied  flow  of  tears  and  of  the  secretion  of  the  mucous  mem- 
brane of  the  nose,  not  unfrequently  observed  on  the  affected  side,  in 
unilateral  facial  atrophy  is  probably  due  to  an  affection  of  the  ganglion  of 

'  Herzenstein.  "  Zur  Physiologie  der  Thranensecretion."  Centralbl.  f.  med. 
Wissensch.,  Bd.  V.,  1867,  p.  513.  . 


TROPHONEUROSES.  277 

the  trigeminus,  or  of  individual  branches  of  the  trigeminus.  Affections  of 
the  sympathetic  may  also  cause  disturbance  of  the  lachrymal  secretion. 
After  traiunatic  injury  of  the  cervical  sympathetic,  increased  flow  of  tears 
is  often  observed  on  the  affected  side,  which  is  usually  accompanied  by 
redness  and  a  rise  of  temperature  on  the  same  side  of  the  head,  and  by 
congestion  of  the  conjunctiva.  These  phenomena  are  probably  due  to 
vaso-motor  paralysis,  and  the  copious  flow  of  tears,  which  often  takes  place 
at  the  end  of  an  attack  of  hemicrania,  is  perhaps  of  a  similar  character. 
Many  anomalies  in  the  flow  of  the  lachrymal  secretion  are  doubtless  of 
central  origin,  such  as  the  copiovis  flow  which  occurs  in  hysterical  attacks, 
and  in  connection  with  emotional  disturbances,  and  these  are  often  asso- 
ciated with  similar  anomalies  of  other  secretions.  Parrot,  for  instance, 
has  observed  a  bloody  condition  of  the  tears  in  connection  with  a  similar 
condition  of  the  perspiration  during  severe  hysterical  convulsions. 

§  129.  Trophoneuroses  of  the  Glands  of  the  Digestive  Tract. — 
The  probable  dependence  of  diabetes  mellitus  upon  the  vaso- 
motor innervation  of  the  liver  has  already  been  mentioned. 
Very  little  is  known  with  respect  to  the  action  of  the  nervous 
system  on  the  formation  of  bile.  Pathological  increase  of  the 
secretions  of  the  stomach  and  intestines  appears  at  times  to 
depend  partly  on  affections  of  the  vagus,  and  partly  on  affections 
of  the  sympathetic  plexuses  and  ganglia.  These  anomalies  often 
depend  upon  a  central  disturbance,  as,  for  instance,  the  vomiting 
and  diarrhoea  which  are  not  unfrequently  caused  by  emotional 
disturbances.  The  considerable  increase  of  the  secretion  of  the 
stomach  observed  in  cases  of  hysterical  vomiting  is  probably  due 
to  irritation  of  the  vagus,  either  in  its  course  or  in  its  central 
origin.  The  vomiting  of  hemicrania,  and  the  increased  secretion 
observed  in  cardialgia  and  pyrosis,  are  also  due  to  vagus  irrita- 
tion, either  at  its  peripheral  or  central  origin.  Considerable 
diminution  of  the  secretions  of  the  stomach  and  intestines,  giving 
rise  to  imperfect  digestion,  wasting,  and  habitual  constipation,  is 
a  frequent  accompaniment  of  grave  neuroses  like  hysteria,  hypo- 
chondriasis, and  mental  diseases ;  or  may  be  induced  by  various 
toxic  agents,  such  as  opium  and  the  preparations  of  lead. 

§  130.  Trophoneuroses  of  the  Glands  of  the  Genito-UHnary 
Apparatus. — The  influence  of  the  nervous  system  on  the 
secretion  of  urine  is  very  great,  but  the  various  channels  by 
means  of  which  it  is  conveyed  are  not  accurately  ascertained. 


278  TROPHONEUROSES. 

Some  of  the  pharmaceutical  agents  which  increase  the  secretion 
appear  to  produce  a  direct  local  irritation  of  the  secreting  nerves 
of  the  kidney,  while  other  agents  increase  the  secretion  by  raising 
the  arterial  tension.  Various  anomalies  of  secretion  may  occur 
from  the  uterus,  vagina,  and  mammae  in  hysterical  females, 
although  it  is  doubtful  in  these  cases  whether  the  disturbance  is 
due  to  affections  of  the  vaso-motor  or  of  special  trophic  nerves. 
In  the  condition  which  has  been  described  under  the  name  of 
irritable  uterus,  hysteralgia,  and  other  terms,  there  are  often,  in 
addition  to  the  sensory  disturbance,  numerous  anomalies  of 
circulation  and  secretion,  which  are  probably  of  reflex  origin. 
Similar  phenomena  may  be  associated  with  cutaneous  neuralgia, 
and  more  especially  with  ilio-lumbar  neuralgia.  In  hysterical 
patients  directly  after  a  paroxysm  there  is  frequently  observed  an 
abundant  secretion  of  mucus,  or  an  increase  of  an  already  existing 
discharge.  Erotic  thoughts  may  give  rise  to  an  obstinate  mucous 
discharge  from  the  vagina  in  the  absence  of  any  organic  lesion. 
Most  of  the  pharmaceutical  agents  which  increase  or  diminish 
the  secretion  of  milk  appear  to  act  through  the  nervous  system. 

In  men  the  condition  known  as  "  irritable  testis "  is  often 
like  the  "  irritable  uterus  "  associated  with  anomalies  of  circula- 
tion and  nutrition.  Swelling  of  the  testicle  and  of  the  sper- 
matic cord,  dilatation  of  vessels,  and  varicocele  are  often  observed 
along  with  neuralgia  of  the  testis  ;  and  these  are  sometimes  of  a 
primary,  sometimes  of  a  secondary  nature.  Many  cases  of  sper- 
matorrhcea,  pollutions,  and  aspermatism  may  probably  be  attri- 
buted to  functional  disturbances  of  secretory  or  motor  nerve 
fibres  arising  in  the  lumbar  portion  of  the  spinal  cord.  Pollu- 
tions appear  generally  to  depend  upon  an  increased  reflex  irri- 
tability from  peripheral  irritation,  or  upon  increased  excitability 
of  the  centre  of  ejaculation  in  the  spinal  cord.  The  latter  con- 
ditition  often  occurs  in  grave  diseases  of  the  cord,  such  as  tabes 
dorsalis ;  and  it  is  sometimes  associated  with  alterations  in  the 
quality  of  the  semen,  as  immobility  or  even  complete  absence  of 
spermatozoa.  Spermatorrhoea,  on  the  other  hand,  which  is  not 
of  purely  mechanical  origin,  as  that  caused  by  enlargement  of 
the  prostate  gland,  depends  less  upon  an  increase  of  the  secretion 
than  upon  a  debility  of  the  vesiculae  seminales,  or  of  the  sper- 
matic conduits. 


TROPHONEUROSES.  279 

{VI. )— NUTRITIVE   AFFECTIONS   OF   THE   VISCERA    (VISCERAL 
TROPHONEUROSES). 

§  181.  It  has  not  yet  been  found  possible  to  separate  the 
vaso-motor  and  trophic  fibres  of  the  viscera  with  respect  either  to 
their  anatomical  distribution  or  to  their  functions  ;  and,  indeed, 
the  existence  of  the  trophic  fibre  can  scarcely  be  said  to  have 
been  proved.  It  is  therefore  very  doubtful  whether  a  particular 
visceral  neurosis  is  to  be  regarded  as  a  vaso-motor  or  a  trophic 
affection.  It  is  very  likely  that  the  congestion,  ecchymoses,  and 
extravasations,  and  probably  also  various  forms  of  hydruria  and 
albuminuria  which  occur  in  connection  with  different  central 
nervous  diseases,  are  due  to  implication  of  the  vaso-motor  nerves. 
Cerebral  hemorrhage  is  frequently  associated  with  pulmonary 
apoplexy  or  pneumonia  of  the  lung  on  the  side  opposite  to  the 
lesion  ;  while  lesions  of  the  nuclei  of  origin  of  the  pneumo- 
gastric,  or  in  the  peripheral  course  of  the  nerve  may  give  rise  to 
pneumonia,  and  fatty  degeneration  of  the  heart.^ 

Notwithstanding  numerous  experiments  on  animals,  it  is  still 
doubtful  whether  the  thoracic  and  abdominal  ganglia  and  plexuses 
contain,  besides  the  vaso-motor  fibres,  specific  trophic  fibres  far 
the  viscera  ;  and  whether,  as  was  first  asserted  by  Axmann,  these 
fibres  arise  out  of  the  spinal  ganglia.  The  assertions  of  numerous 
experimentalists,  amongst  whom  may  be  mentioned  Bernard, 
Samuel,  Budge,  Adrian,  Schmidt,  and  Schiff,  are  extremely  con- 
tradictory. The  most  frequent  consequences  of  extirpation  or 
destruction  of  the  coeliac  and  mesenteric  plexuses  are  congestion 
and  extravasation  of  the  stomach  and  intestines,  enlargement 
and  congestion  of  the  liver,  and  diabetes,  all  of  them  symptoms 
which  are  most  likely  caused  by  vaso-motor  paralysis.  The 
reaction  of  the  operation  on  the  organism  as  a  whole  is  also 
very  variable,  some  authors  having  noted  a  transitory  emacia- 
tion, while  others  found  that  animals  have  become  fatter  after 
extirpation  of  the  cceliac  ganglion. 

'  See  Arnozfin.  Des  lesions  trophiques  cons^cutives  aux  maladies  du  system« 
nerveiix.    Paris,  1880,    p.  194  et  seq. 


280 


CHAPTER   VII. 


GENEKAL   MORBID   ANATOMY  AND   PHYSIOLOGY. 

It  will  be  useful  to  consider  the  leading  outlines  of  tlie  morbid 
anatomy  of  the  nervous  system,  before  entering  upon  details  in 
the  special  part.  The  nervous  tissues  consist,  as  already  men- 
tioned, of  cells  and  fibres  packed  together  by  means  of  connective 
tissue  (neuroglia)  so  as  to  form  organs,  and  supplied  with  blood- 
vessels, lymph  spaces  and  vessels,  and  with  blood.  Now  the 
nerve  cells  and  fibres  may  themselves  be  primarily  diseased, 
constituting  the  'parenchymatous  affections  of  the  nervous 
system ;  or  they  may  be  secondarily  diseased,  the  primary  affec- 
tion occurring  in  the  connective  tissue,  the  vessels,  or  the  blood ; 
or  the  disease  may  begin  in  neighbouring  organs  and  extend 
from  these  to  the  nervous  tissues.  But  inasmuch  as  the  paren- 
chymatous diseases  always  cause  secondary  changes  in  the  con- 
nective tissues,  blood-vessels,  and  blood,  and  the  diseases  of  the 
latter  react  on  the  parenchyma,  it  is  not  by  any  means  always 
easy  to  distinguish  between  primary  parenchymatous  disease  on 
the  one  hand,  and  the  diseases  of  the  connective  tissues  and  the 
vascular  and  toxic  neuroses  on  the  other.  The  term  lesion  is 
used  as  a  generic  expression  for  any  morbid  alteration  of  tissue, 
whether  this  alteration  be  or  be  not  attended  by  such  structural 
changes  as  can  be  recognised  after  death  by  our  means  of 
research. 

§  132.  Classification  of  Lesions  of  the  Nervous  System. 

Lesions  of  the  nervous  system  may  be  classified  :  I.  According 
to  their  nature ;  II.  According  to  their  form ;  III.  According  to 
the  functional  disturbances  they  produce. 


MORBID   ANATOMY  AND   PHYSIOLOGY.  281 

(I.)    CLASSIFICATION   ACCORDING   TO   THE   NATURE   OF   THE 

LESION. 

(1)  Inflammation. — Every  part  of  the  nervous  system  is  sub- 
ject to  inflammation,  which,  like  inflammation  of  other  tissues, 
may  be  acute,  sub-acute,  or  chronic  with  respect  to  its  course  and 
development.  When  the  affection  is  acute  it  generally  ends  in 
complete  disintegration  of  the  affected  tissue,  which,  on  being 
mixed  up  with  fluid  and  morphological  elements  effused  from 
the  blood-vessels,  presents  a  pulpy  mass  technically  called 
softening.  When  the  inflammatory  process  is  chronic  the  tissue 
undergoes  degeneration ;  but  inasmuch  as  degeneration  may 
occur  independently  of  inflammation,  both  kinds  may  be  included 
in  one  group. 

(2)  Degenerations. — Degenerations  of  nervous  tissues  are  of 
various  kinds ;  but  inasmuch  as  in  all  of  them  the  nervous  tissue, 
instead  of  undergoing  softening  as  in  acute  inflammation,  becomes 
somewhat  denser  than  usual,  they  are  called  scleroses.  From  the 
colour  of  the  altered  tissue,  it  is  sometimes  called  grey  degenera- 
tion. Both  inflammations  and  degenerations  include  affections 
which  have  begun  in  the  connective  tissues  or  neuroglia,  the 
vessels  and  their  adventitise,  or  the  blood  itself,  as  well  as  those 
which  are  primarily  of  parenchymatous  origin. 

(3)  Vascular  Lesions. — Besides  the  vascular  lesions  w^hich 
accompany  all  inflammatory  and  degenerative  processes,  other 
very  important  diseases  in  connection  with  the  vessels  must  be 
mentioned. 

(a)  Hyperoemia  and  Anaemia. — The  vessels  are  at  times 
actively  dilated  so  that  an  undue  quantity  of  blood  is  sent  to 
portions  of  the  nervous  system,  while  they  are  at  other  times 
contracted  so  that  the  normal  quantity  is  diminished.  The 
hypersemia  may  at  times  be  active  and  due  to  high  arterial 
tension  and  active  dilatation  of  the  arterioles,  while  at  other 
times  it  is  passive,  and  is  then  caused  by  some  obstruction  of  the 
blood  along  the  large  veins  of  the  body.  The  anaemia  to  which 
the  nervous  system  is  subject  does  not  differ  from  the  anaemia  of 
other  organs,  and  may  therefore  be  due  to  an  alteration  of  the 
quality  as  well  as  the  quantity  of  the  blood. 

( 6 )  Hcemorrhage. — Rupture  of  vessels  with  consequent 
haemorrhage  is  a  very  common  cause  of  disease  of  the  central 


282  MORBID  ANATOMY  AND  PHYSIOLOGT.- 

nervous  organs,  and  especially  of  the  cerebrum.  The  rupture 
may  at  times  be  due  to  accidental  injury,  but  more  frequently  it 
occurs  in  the  degenerative  period  of  life,  and  is  then  caused  by 
various  degenerations  of  the  coats  of  the  vessels,  such  as  atheroma 
and  the  fibrosis  which  accompanies  Bright's  disease. 

(c)  Embolism  and  Thrombosis. — The  morbid,  processes  of 
embolism  and  thrombosis,  when  they  occur  in  the  nervous 
system,  are  essentially  the  same  as  in  any  of  the  other  organs  of 
the  body.  The  sudden  arrest  of  the  circulation,  caused  by  oblite- 
ration of  an  artery,  causes  intense  anaemia  and  loss  of  function 
of  the  part  to  which  its  branches  are  distributed.  The  centre  of 
the  iscbsemic  region  usually  undergoes  necrobiosis,  and  its  sub- 
stance becomes  altered  into  a  soft  pulpy  mass  closely  resembling 
inflammatory  softening. 

(4)  Toxic  Lesions. — Various  chemical  agents  circulating  in 
the  blood  induce  morbid  alterations  of  the  nervous  tissues. 

(5)  Traumatic  Injuries. — Wounds,  contusions,  and  other 
traumatic  influences  cause  so  many  alterations  of  nervous  tissues 
that  their  results  deserve  to  be  mentioned  amongst  the  morbid 
lesions  of  the  nervous  system. 

(6)  Compression  of  Nervous  Tissues. — The  nervous  tissues 
are  frequently  subjected  to  sudden  or  gradual  compression  from 
various  causes.  One  of  the  most  frequent  causes  of  compression 
is  the  gradual  encroachment  on  the  tissues  of  new  formations, 
no  matter  whether  the  growth  be  outside  the  nervous  tissues  or 
extra-neural,  or  in  the  substance  of  the  tissues  or  intra-neural. 
Other  causes  of  compression  are  fractures  of  the  cranium,  dis- 
locations, fractures  and  curvatures  of  the  vertebrae,  the  formation 
and  subsequent  enlargement  of  abscesses  and  aneurisms,  and  the 
growth  of  cysticerci  and  other  parasites.  Inflammatory  effusions 
and  thickenings  of  the  membranes  of  the  brain  or  cord,  or  of  the 
sheaths  of  nerves,  also  injure  the  nerve  tissues  by  compression  as 
well  as  by  extension  of  the  morbid  process  to  the  nervous  tissues 
themselves. 

(II.)— CLASSLFICATION   ACCORDING   TO    THE    FORM    OF   THE 

LESION. 

( 1 )  Circumscribed  or  Focal  and  Diffused  Lesions — 
Systematic  Diseases. — When  a  lesion  is  circumscribed  within 


MORBID   ANATOMY  AND   PHYSIOLOGY.  283 

definite  limits  it  is  called  a  focal  lesion,  and  when  it  extends 
over  an  indefinite  area  with  irregular  limits  it  is  called  a  diffused 
lesion.  When  the  lesion  is  limited  to  a  portion  of  the  nervous 
system  which  possesses  a  distinct  functional  unity,  it  is  called  a 
system-disease  or  a  systematic  lesion;  and  when  several  phy- 
siological tracts  are  implicated,  it  is  called  a  mixed  disease,  or 
indiscriTninate  lesion.  A  lesion  limited  to  the  pyramidal  tract 
in  the  spinal  cord  is  a  good  example  of  a  systematic  lesion,  and 
a  transverse  myelitis  of  an  indiscriminate  lesion. 

(2)  Molecular,  Molar,  and  Histological  Lesions. — In  order 
to  study  these  diseases  under  the  simplest  conditions,  let  us 
suppose  that  the  sciatic  nerve  of  a  frog  is  isolated,  with  the 
gastrocnemius  muscle  attached.  On  being  stimulated  by  a 
strong  faradic  current,  the  muscle  immediately  contracts  ;  but  a 
second  shock  through  the  nerve  is  powerless  to  induce  a  con- 
traction— the  nerve  is  paralysed.  During  the  passage  of  the 
nerve  from  almost  perfect  health  to  complete,  though  temporary, 
paralysis,  the  change  which  it  has  undergone  is  such  as  cannot 
be  detected  by  the  most  refined  chemistry,  or  by  the  aid  of  the 
highest  powers  of  the  microscope.  In  such  a  case  we  assume 
that  the  molecules  of  the  axis  cylinder  have  come  to  a  condition 
of  stable  equilibrium ;  hence  the  cause  of  tbe  loss  of  function 
may  be  described  as  a  molecular  lesion.  It  need  scarcely  be 
added  that  a  molecular  lesion  may  also  give  rise  to  excess,  as 
well  as  diminution,  of  functional  activity.  The  lesion  which  I 
have  called  molecular  has  also  been  termed  functional,  from 
the  fact  that  the  part  affected,  while  giving  rise  to  definite 
functional  disturbances,  does  not  present  any  apparent  structural 
changes. 

But  if  a  portion  of  the  sciatic  nerve  be  crushed  or  cut,  the 
conductivity  of  the  nerve  is  destroyed  at  the  point  of  injury, 
and  a  faradic  current  applied  to  the  nerve  on  the  central  side  of 
the  injury  will  not  cause  the  muscle  to  contract.  The  loss  of 
function  in  this  case  is  caused  by  a  lesion,  which  can  be  recog- 
nised by  the  naked  eye  ;  hence  it  may  be  called  a  molar  lesion. 
Dr.  Hughlings  Jackson  has  proposed  to  call  the  molar  lesion  by 
the  name  of  "  coarse  disease,"  and  the  molecular  lesion  by  the 
name  of  "  fine  disease  " — names  which,  at  least,  possess  the 
merit  of  explaining  themselves.     Between  the  fine  or  the  mole- 


284  MORBID  ANATOMY  AND  PHYSIOLOGY. 

cular  lesion  on  the  one  hand,  and  the  coarse  or  molar  lesion  on 
the  other,  another  variety  may  be  interposed.  When  the  mor- 
phological elements  of  the  nervous  tissues  themselves,  or  of  the 
tissues  by  which  the  nervous  elements  are  surrounded,  undergo 
alterations  which  can  be  recognised  by  the  aid  of  the  microscope, 
the  morbid  change  of  structure  may  be  called  a,  histological 
lesion. 

(III.) -CLASSIFICATION  ACCORDING    TO    THE   ALTERATIONS    OF 
FUNCTION  PRODUCED  BY  THE  LESION. 

(1)  Irritative  and  Depressive  Lesions. — When  the  morbid 
alteration  is  attended  during  life  with  excess  of  functional 
activity,  it  is  inferred  that  the  lesion  is  one  of  an  irritative 
character,  or,  in  other  words,  it  is  inferred  that  the  irritability  of 
the  cells  and  fibres  of  the  part  affected  is  increased.  The  opposite 
condition,  in  which  the  irritability  is  diminished  or  abolished, 
deserves  a  special  name,  and  may  be  called  a  depressive  lesion. 

(2)  Discharging  and  Destroying  Lesions. — The  morbid  altera- 
tions which  are  attended  by  paroxysmal  and  excessive  liberations 
of  energy  have  been  called  by  Dr.  Hughlings  Jackson  discharging 
lesions.  We  have  seen  that  the  nerve  cells  are  the  main  gene- 
rators and  accumulators  of  energy,  hence  these  lesions  always 
implicate  the  grey  substance,  although  it  is  not  always  easy  to 
draw  a  sharp  line  of  distinction  between  discharges  of  energy 
from  grey  substance  and  those  which  result  from  irritation  of 
nerve  fibres.  When  the  affection  is  accompanied  by  a  distinct 
destruction  of  nerve  tissue,  such  as  occurs  in  haemorrhage  into 
the  substance  of  the  brain.  Dr.  Hughlings  Jackson  has  named  it 
a  destroying  lesion. 

§  ]33.  Relation  between  Morbid  Nervous  Structures  and 
Functions. — It  has  already  been  stated  that  when  the  irritability 
of  the  nervous  tissues  is  increased,  or,  in  other  words,  when  the 
molecules  of  the  active  portion  of  these  tissues  occupy  positions 
of  unstable  equilibrium,  the  functional  activity  of  the  part 
affected  is  increased ;  and,  conversely,  when  the  molecules  occupy 
relatively  stable  positions,  the  functional  activity  of  the  part  is 
diminished.  The  causes  which  raise  or  depress  the  irritability 
have  already  been  described  (§  16),  and  when  one  of  these  causes 


MORBID  ANATOMY  AND  PHYSIOLOGY,  285 

is  operative  the  capacity  of  the  affected  part  for  function  under- 
goes corresponding  variations.  Increased  irritability  of  a  part 
demands  increased  activity  of  material  exchanges,  which  in  its 
turn  renders  necessary  an  increased  supply  of  nutriment;  and, 
conversely,  when  the  irritability  is  depressed  the  material  ex- 
changes and  the  nutrient  supply  are  diminished.  It  may  be 
inferred,  therefore,  that  a  free  arterial  supply  to  a  part,  or  a 
flushed  condition  of  the  arterioles,  is  the  necessary  correlative  of 
increased  irritability ;  and,  conversely,  that  a  diminished  arterial 
supply,  with  an  empty  and  contracted  condition  of  the  arterioles, 
is  the  necessary  correlative  of  diminished  irritability.  These 
statements,  however,  can  only  be  accepted  as  true  within  certain 
limits  and  with  numerous  qualifications.  When  the  brain,  for 
instance,  is  very  freely  supplied  with  blood  so  that  its  substance 
becomes  congested,  the  irritability  of  the  tissues  is  no  doubt  at 
first  increased.  It  must,  however,  be  remembered  that  the 
cranium  is  unyielding,  and  its  contents  practically  incompressible, 
so  that  no  additional  quantity  of  blood  can  enter  into  the  intra- 
cranial vessels  except  by  displacing  a  corresponding  quantity  of 
some  other  fluid.  When,  therefore,  the  vessels  become  dilated 
beyond  certain  narrow  limits  the  nervous  tissue  becomes  com- 
pressed, the  material  exchanges  within  the  cranium  become  less 
than  when  the  circulation  passes  in  normal  quantity  and  under 
normal  pressure,  and  the  functional  activity  of  the  organ  is 
diminished  or  abolished.  A  similar  process  no  doubt  occurs  in 
the  spinal  cord  and  nerve  trunks.  Congestion  in  them,  when 
carried  beyond  certain  limits,  is  also  attended  with  diminution 
of  function,  due,  no  doubt,  to  compression  of  the  nerve  tissues 
by  the  dilated  vessels.  The  irritative  lesion  is  attended  with 
increased  nutritive  activity,  and  consequently  with  free  arterial 
supply ;  but  this  lesion  is  exceedingly  apt  to  terminate  in  the 
opposite  condition  of  diminished  nutrition  and  functional  activity. 
The  first  stage  of  inflammation,  for  instance,  is  an  irritative 
lesion,  and  it  is  attended  by  excess  of  functional  activity,  mani- 
festing itself  by  symptoms  of  hypersesthesia  and  hyperkinesis ; 
but  when  the  nervous  tissues  become  partly  compressed  by 
effused  products  and  partly  disorganised  by  internal  changes, 
;the  lesion  becomes  depressive,  and  the  symptoms  of  excess  give 
place  to  those  of  diminution  of  function ;  in  other  words,  the 


286  MORBID  ANATOMY  AND  PHYSIOLOGY. 

symptoms  of  hypersesthesia  and  hyperkinesis  give  place  to  those 
of  anaesthesia  and  akinesis. 

But  if  excess  of  nutrient  activity  is  not  always  accompanied 
by  increased  functional  activity,  neither  is  diminished  nutrient 
activity  always  accompanied  by  diminution  of  functional  activity. 
We  have  indeed  seen  (§  16)  that  when  the  nutrition  of  a  nerve 
fibre  is  gradually  lessened  its  irritability  is  increased  instead"  of 
being  diminished.  The  stock  of  irritable  matter  which  the  nerve 
fibre  possesses  is  no  doubt  less  under  these  circumstances,  but 
an  increased  readiness  to  discharge  the  energy  is  manifested ; 
and  it  is  notorious  that  feeble  and  ansemic  persons  manifest  an 
undue  readiness  to  respond  to  the  action  of  stimuli  of  all  kinds, 
a  condition  which  is  correctly  designated  nervous  irritability. 
One  other  important  consideration  must  be  taken  into  account 
before  the  amount  of  nourishment  supplied  to  an  organ  or  a 
tissue  can  be  accepted  as  in  any  way  a  measure  of  the  functional 
activity  of  the  latter.  We  have  seen  that,  when  a  strong  faradic 
current  is  sent  through  the  sciatic  nerve  of  a  frog,  the  gastro- 
cnemius muscle  contracts  strongly ;  but  a  subsequent  current 
passed  through  the  nerve  is  followed  by  no  reaction  until  the 
irritability  of  the  nerve  is  restored  by  the  absorption  of  more 
nourishment.  A  similar  process  doubtless  occurs  in  disease  of 
the  nervous  system.  When  a  part  is  supplied  with  an  excessive 
amount  of  nourishment,  the  tissues  become  so  irritable  that  they 
discharge  readily,  either  spontaneously,  or  in  response  to  stimuli 
which  would  not  affect  them  under  normal  conditions.  Under 
these  circumstances,  excessive  discharges  of  nervous  energy  readily 
take  place,  and  these  are  followed  by  temporary  loss  of  irritability, 
and  the  tissue  becomes  incapable  for  a  time  of  performing  its 
normal  functions.  The  excessive  liberations  of  energy  from  the 
cortex  of  the  brain,  which  occasion  epileptic  attacks,  for  instance, 
are  accompanied  by  loss  of  consciousness,  which  lasts  for  a  con- 
siderable time,  and  the  convulsive  phenomena  are  not  unfre- 
quently  followed  by  temporary  motor  paralysis.  When  the  energy 
of  the  discharging  lesion  is  once  liberated,  the  part  affected 
becomes  incapable  of  performing  its  functions,  until  its  irritability 
is  restored  by  the  absorption  of  a  fresh  stock  of  irritable  matter. 
The  primary  effect  of  almost  all  chemical  agents  on  the  nervous 
system  is  to  stimulate  it,  and  to  increase  its  functional  activity, 


MORBID   ANATOMY  AND  PHYSIOLOGY.  287 

while  their  secondary  effect  is  to  depress  or  abolish  its  functional 
activity.  The  stimulant  action  of  alcohol  on  the  brain,  for 
instance,  is  followed  by  a  stage  of  depression,  which  may  amount 
to  complete  abolition  of  the  cerebral  functions  or  coma.  Strych- 
nine increases  the  irritability  of  the  grey  substance  of  the  spinal 
cord ;  but  the  reflex  actions,  which  are  at  first  greatly  exag- 
gerated, become  ultimately  abolished,  and  the  animal  poisoned 
by  strychnine  often  dies  from  paralysis.  Curara,  which  may  be 
taken  as  the  type  of  nervous  sedatives,  paralyses  the  termina- 
tions of  the  motor  nerves,  yet  Bernard^  proved  that  it  first  in- 
creases the  irritability  of  the  fibres. 

The  direct  tendency  of  all  destroying  lesions  is  to  abolish 
function.  It  must,  however,  be  remembered  that  these  lesions 
are  frequently  surrounded  by  a  zone  of  nervous  tissue,  which  is 
in  a  state  of  irritation,  and  the  prominent  symptoms  of  the  affec- 
tion are  often  produced  by  this  zone,  consequently  the  symptoms 
are  indicative  of  excess  of  functional  activity.  A  gummatous 
tumour,  for  instance,  in  the  cortex  of  the  brain  is  generally 
declared  by  epileptoid  convulsions ;  yet  the  direct  tendency  of 
the  tumour,  in  so  far  as  it  has  destroyed  and  replaced  nervous 
tissue,  is  to  abolish  function.  In  such  cases,  both  the  direct  a,iid 
indirect  effects  of  the  tumour  are  often  manifested ;  the  former 
by  paralytic  and  the  latter  by  convulsive  symptoms.  Even  the 
ischsemic  softening,  caused  by  plugging  of  vessels,  is  often  sur- 
rounded by  a  congestive  zone  of  tissue,  and  the  latter  may  give 
rise  to  symptoms  of  irritation. 

*  Bernard  (C).    Legons  de  Pathologie  Expferimentale,  p.  220. 


288 


CHAPTER   VIII. 


GENERAL  DIAGNOSIS  AND  PROGNOSIS. 

(I.)— DIAGNOSIS. 

§  134,  The  diagnosis  of  disease  of  the  nervous  system  may 
be  divided  into  (I.)  the  Clinical,  (II.)  the  Topographical,  and 
(III.)  the  Pathological  Diagnosis. 

(I.)  Clinical  Diagnosis. — It  has  already  been  seen  that 
diseases  admit  of  a  clinical  classification,  according  to  the 
symptoms  manifested  during  life,  and  irrespective  of  the  morbid 
changes  which  underlie  these.  The  various  forms  of  paralysis, 
for  instance,  may  be  divided  clinically  into  paraplegia,  hemi- 
plegia, or  monoplegia ;  and  a  fundamental  clinical  distinction  is 
made  when  it  is  recognised  that  a  particular  case  of  paralysis 
belongs  to  the  atrophic  or  to  the  spasmodic  group,  inasmuch  as 
the  clinical  diagnosis  can  be  readily  translated  into  the  correla- 
tive topographical  division  of  spino-peripheral  and  cerebro-spinal 
paralysis  respectively.  Our  knowledge  of  many  diseases,  how- 
ever, is  so  slender  that  they  only  admit  of  a  clinical  diagnosis. 
When  general  convulsions,  for  example,  occur  at  irregular  inter- 
vals and  in  association  with  various  emotional  manifestations,  we 
call  them  hysteria ;  when  they  recur  at  regular  intervals  in  the 
absence  of  such  manifestations,  we  call  them  epilepsy;  and  when 
they  occur  as  an  acute  affection  without  showing  a  tendency  to 
periodical  recurrence,  we  call  them  eclampsia;  and  eclamptic 
convulsions  are  again  subdivided  according  to  the  cause  of  the 
symptoms  into  toxic,  puerperal,  uraemic,  febrile,  and  reflex  con- 
vulsions ;  and  when  no  cause  for  them  can  be  assigned,  we  call 
them  idiopathic  convulsions.  To  name  a  particular  disease  or 
group  of  symptoms  reflex  or  febrile  convulsions  is  not  a  scientific 


GENERAL  DIAGNOSIS  AND   PROGNOSIS.  289 

diasfnosis,  but  it  is  often  the  best  we  can  make ;  and  we  must 
remember  that  medicine  is  a  practical  science  or  art,  and  that  it 
is  incumbent  upon  us  to  sabordinate  our  classification  and  diag- 
nosis of  disease  to  the  practical  aim  of  treatment.  To  call, 
therefore,  a  particular  group  of  symptoms  reflex  or  febrile  con- 
vulsions is  by  no  means  a  bad  practical  diagnosis,  and  even  in 
those  diseases  in  which  our  knowledge  is  sufficiently  advanced  to 
enable  us  to  adopt  a  pathological  classification  a  careful  clinical 
examination  is  a  necessary  preliminary  to  the  formation  of  a 
scientific  diagnosis. 

(II.)  TopograpJiiccd  Diagnosis. — The  aim  of  topographical 
diagnosis  is  to  determine  with  accuracy  the  seat  of  the  affection, 
or  the  localisation  of  the  lesion,  as  it  is  now  called.  This  subject 
has  been  incidentally  treated  of  when  describing  and,  to  a  certain 
extent,  interpreting  the  symptoms  of  nervous  disease ;  hence  only 
brief  reference  will  be  made  to  it  at  present.  One  useful  rule  in 
determining  the  localisation  of  the  disease  is  to  place  the  seat  of 
the  lesion  at  a  point  where  all  the  affected  paths  lie  near  together. 
This  rule,  however,  demands  considerable  caution  in  its  applica- 
tion, inasmuch  as  a  plurality  of  lesions  is  frequently  observed. 
The  most  practically  useful  classification  of  nervous  diseases  for 
the  purposes  of  topographical  diagnosis  is  that  which  divides 
them  into  (1)  Peripheral,  (2)  Spinal,  and  (3)  Encephalic  lesions. 

(1)  Peripheral  Lesions. — In  peripheral  lesions  the  functional 
disorders  are  generally  limited  to  single  nerves  or  branches  of 
nerves,  and  the  localisation  of  the  sensory,  motor,  vaso-motor, 
and  trophic  disturbances  coincides  with  the  distribution  of  the 
affected  nerve.  The  presence  of  muscular  atrophy,  especiailly 
when  the  muscles  are  supplied  by  a  single  nerve,  combined  with 
the  appearance  of  the  reaction  of  degeneration  in  the  affected 
muscles,  the  complete  absence  of  all  reflex  action,  and  of  all 
weakness  of  the  bladder  and  of  the  sexual  functions,  are  in 
favour  of  peripheral  paralysis.  Acute  disease  of  the  anterior 
grey  horns  of  the  cord  gives  rise  to  muscular  atrophy,  the 
reaction  of  degeneration,  absence  of  the  reflexes  in  the  paralysed 
muscles,  while  the  bladder  and  sexual  functions  are  unaffected ; 
but  in  the  latter  case  the  muscles  affected  are  grouped  according 
as  they  are  associated  in  their  actions,  while  in  peripheral 
paralysis  they  are  grouped  according  to  the  distribution  of 
VOL.  I,  T 


290  GENEKAL   DIAGNOSIS   AND   PEOGNOSIS. 

individual  nerves  and  their  branches.  Valuable  information 
may  be  obtained  from  the  history  of  the  onset  of  the  affection, 
which  will  enable  us  to  distinguish  between  peripheric  paralysis 
and  atrophic  spinal  paralysis.  The  latter  disease  occurs  sud- 
denly, and  its  onset  is  generally  attended  with  severe  general 
symptoms,  and  it  occurs  more  frequently  in  childhood  than  in 
later  life ;  while  the  former  disease  may  occur  at  any  period  of 
life,  and  when  it  occurs  suddenly  it  is  generally  caused  by  some 
injury  in  the  course  of  the  nerve,  which  leaves  a  permanent 
cicatrix  or  other  indication  of  the  peripheral  origin  of  the  lesion. 
In  peripheral  paralysis,  aneesthesia,  limited  to  the  distribution  of 
the  affected  nerve,  is  generally  present ;  while  the  spinal  forms 
of  atrophic  paralysis  are  characterised  by  complete  absence  of 
sensory  disturbances. 

It  has  been  asserted  by  Weir  Mitchell  that,  in  disease  of  the 
peripheral  nerves,  retardation  in  the  conduction  of  sensation  is' 
never  manifested.  When  a  tumour  simultaneously  presses  upon 
a  large  number  of  nerves,  such  as  the  cauda  equina,  or  on  the 
nerves  at  the  base  of  the  skull,  it  is  not  always  easy  to  distinguish 
between  paralysis  of  peripheral  and  of  central  origin.  The  rules 
to  be  followed  in  distinguishing  those  affections  must  be  reserved 
for  the  special  part. 

(2)  Spinal  Lesions. — The  most  characteristic  feature  of  spinal 
diseases  is  a  nearly  uniform  ascending  paralysis  of  both  sides, 
constituting  paraplegia.  The  symmetrical  groups  of  muscles  of 
the  lower  extremities,  trunk,  abdomen,  and  upper  extremities 
are  paralysed  progressively  from  below  upwards,  according  as 
the  disease  ascends  from  the  lumbar  through  the  dorsal  to  the 
cervical  region  of  the  cord.  Sensory  disturbances  are  also  usually 
present,  though  they  are  not  always  equal  in  extent  and  intensity 
to  the  motor  affections.  When  the  motor  paralysis  is  limited 
to  one  half  of  the  lower  part  of  the  body  (bemi-paraplegia)  the 
sensory  and  motor  disturbances  cross,  so  that  the  one  occupies 
the  one  side  and  the  other  the  corresponding  parts  on  the  oppo- 
site side.  The  spinal  sensory  disturbances  frequently  consist 
merely  of  retardation  of  sensory  conduction  and  various  parses- 
thesise,  such  as  numbness,  formication,  and  girdle  sensations  at 
the  upper  limit  of  the  motor  affections.  Sensory  disturbances 
are  absent  in  the  spinal  paralysis  of  children  and  allied  forms,  a 


GENERAL  DIAGNOSIS   AND  PROGNOSIS.  291 

fact  which  constitutes  an  important  element  in  the  diagnosis 
between  them  and  atrophic  paraly^s  of  peripheral  origin.  Spinal 
affections  are  also  frequently  accompanied  by  disturbances  in  the 
functions  of  the  bladder,  rectum,  and  sexual  organs,  and  when 
the  cervical  region  is  affected  paralytic  myosis  is  often  present. 
The  condition  of  the  various  reflexes,  both  superficial  and  deep, 
are  exceedingly  valuable  in  the  diagnosis  of  spinal  affections. 
These  reflexes  may  be  either  exaggerated,  diminished,  or 
abolished,  and  thus  valuable  information  is  afforded,  both  with 
regard  to  the  nature  of  the  lesion,  whether  irritative  or  depressive, 
and  to  the  level  at  which  the  cord  is  affected.  The  various  vaso- 
motor and  trophic  affections,  especially  the  appearance  of  acute 
bed-sores  over  the  sacrum,  also  afford  valuable  evidence  of  the 
presence  of  spinal  disease ;  while  the  absence  of  disturbances  of 
the  cranial  nerves,  including  the  special  senses,  and  of  all 
psychical  disturbances,  aid  us  in  distinguishing  spinal  from 
cerebral  disease. 

(3)  Encephalic  Lesions. — The  main  points  on  which  we  rely 
in  distinguishing  cerebral  from  spinal  and  peripheral  disease  are 
the  hemiplegic  distribution  of  the  sensory  and  motor  disturbances, 
both  being  limited  to  the  same  side  of  the  body,  and  generally 
of  very  unequal  intensity;  the  absence  of  all  trophic  disturbances; 
the  presence  of  normal  electric  reaction  of  muscles  and  nerves; 
the  retention  or  exaggeration  of  all  reflex  acts;  and  the  retention 
of  associated  and  automatic  movements,  and  of  the  rectal  and 
vesical  functions.  In  intracranial  disease  the  cranial  nerves  are 
frequently  implicated,  while  disturbances  of  speech  and  of  the 
higher  mental  faculties,  both  intellectual  and  emotional,  are 
generally  observed.  The  presence  of  headache,  giddiness,  and 
unaccountable  vomiting  also  afford  valuable  diagnostic  signs  of 
many  forms  of  cerebral  disease.  The  diagnostic  significance  of 
the  various  forms  of  spasm  and  convulsion,  muscular  tension, 
contractures,  and  the  different  forms  of  tremor,  is  too  complicated 
a  subject  to  be  fully  discussed  at  present,  and  must  be  therefore 
reserved  for  future  mention. 

(III.)  Pathological  Diagnosis. — The  aim  of  pathological 
diagnosis  is  to  determine  the  nature  of  the  lesion,  no  matter 
where  it  may  be  situated.  It  may  be  laid  down  as  a  general 
rule,  but  one  requiring  numerous  qualifications  and  cautions  in 


292  GENERAL   DIAGNOSIS  AND  PROGNOSIS. 

practice,  that  a  lesion  which,  in  the  absence  of  traumatic  and 
toxic  influences,  develops  symptoms  of  depression  in  the  course 
of  a  few  minutes,  or  a  few  hours,  is  of  vascular  origin  ;  that  a 
lesion  which  takes  from  a  few  days  to  a  few  weeks  for  the  full 
development  of  the  symptoms,  and  in  which  the  symptoms  of 
irritation  are  followed  by  those  of  depression,  is  of  infiammatory 
origin ;  and  that  a  lesion  which  takes  from  two  to  six  months, 
or  longer,  for  the  full  development  of  its  symptoms,  and  in 
which  the  primary  symptoms  of  irritation  are  either  absent  or 
obscured  by  the  more  prominent  symptoms  of  depression,  is  of 
degenerative  origin,  or  due  to  a  slow  and  gradual  compression  of 
nervous  tissue  by  the  growth  of  a  new  formation, 

(1)  Vascular  Lesions. — The  vascular  lesions,  which  are  the  most 
frequent  causes  of  disease  of  the  nervous  system,  are  rupture  and 
haemorrhage,  embolism,  and  thrombosis.  The  lesion  is  more  likely 
to  be  due  to  haemorrhage  if  the  affection  occur  after  forty-five 
years  of  age  and  during  the  degenerative  period  of  life,  if  the 
arteries  at  the  wrist  and  temples  be  hard  and  knotty,  if  there  be 
some  hypertrophy  of  the  left  ventricle  along  with  an  accentuated 
second  sound  of  metallic  quality  in  the  aortic  area,  if  the  patient 
be  suffering  from  chronic  Bright's  disease  and  its  attendant 
degeneration  of  arteries  and  high  arterial  tension,  and  if  a  well 
marked  arcus  senilis  or  other  sis^ns  of  degeneration  of  tissue  be 
present.  It  is  also  probable  that  emphysema  and  cardiac 
diseases  favour  hsemorrhage  by  producing  passive  congestion  of 
the  brain. 

The  lesion  is  more  likely  to  be  embolic  if  the  affection  occur 
prior  to  the  degenerative  period  of  life,  if  there  be  valvular 
disease  of  the  heart;  and,  when  the  affection  is  of  cerebral  origin 
as  it  generally  is,  if  loss  of  speech  or  aphasia  be  a  prominent 
symptom.  When  the  lesion  is  due  to  thrombosis  the  symptoms 
are,  as  a  rule,  slower  in  their  development  than  in  haemorrhage 
or  embolism.  The  signs  which  favour  the  idea  that  the  lesion 
is  due  to  thrombosis  are,  the  supervention  of  symptoms  more 
or  less  similar  to  those  which  would  be  caused  by  hsemorrhage 
or  embolus,  along  with  evidence  that  the  arteries  are  affected 
either  by  atheroma,  calcification,  or  syphilitic  endoarteritis. 

(2)  Inflammatory  Lesions. — The  inflammatory  nature  of  the 
lesion  must  be  determined  by  the  mode  of  onset  being  more 


GENERAL   DIAGNOSIS  AND   PROGNOSIS.  293 

gradual  than  in  vascular  lesions,  the  symptoms  of  depression 
being  preceded  by  those  of  irritation,  and  the  presence  during 
the  development  of  the  affection  of  elevation  of  temperature 
and  other  febrile  symptoms. 

(3)  Degenerative  Lesions. — In  degenerative  lesions  the  mode 
of  onset  is  still  more  gradual  than  in  inflammatory  lesions. 
Symptoms  of  irritation  are  almost  or  entirely  absent  during  the 
whole  progress  of  the  case ;  while  there  is  entire  absence  of 
pyrexia  as  the  result  of  the  lesion. 

(4)  New  Formations. — Tumours  which  compress  the  peri- 
pheral nerves  can  usually  be  detected  by  ordinary  physical  ex- 
amination, and  it  is  only  in  the  case  where  the  tumour  occupies 
the  vertebral  canal  or  the  cavity  of  the  cranium  that  any  special 
difficulty  of  diagnosis  presents  itself.  The  development  of  the 
symptoms  produced  by  the  growth  of  tumours  is  never  acute, 
and  rarely  very  chronic,  but  no  great  reliance  can  be  placed  on 
this  fact  as  evidence  in  diagnosis.  The  most  valuable  evidence 
is,  indeed,  obtained  from  the  history  of  the  development  and 
the  grouping  of  the  symptoms ;  and  the  presence  of  an  intra- 
vertebral  or  intracranial  tumour  must  be  inferred  principally  by 
the  method  of  exclusion ;  or,  in  other  words,  by  showing  that 
the  symptoms  could  not  be  caused  by  any  other  known  disease. 
After  ha^ving  determined  that  the  symptoms  are  due  to  the 
growth  of  a  new  formation,  the  question  as  to  the  nature  of  the 
growth  remains  unanswered.  It  would  lead  us  too  far  to  enter 
on  this  wide  subject  at  present ;  but  much  valuable  information 
with  reference  to  this  question  may  be  obtained  from  a  close 
study  of  the  constitution  of  the  patient,  taking  special  account 
of  hereditary  influences.  If,  for  instance,  the  symptoms  of 
intracranial  tumour  are  present  in  a  child,  whose  sister  has 
suffered  from  scrofulous  swelling  of  the  knee-joint,  or  in  whose 
family  history  other  unmistakable  evidence  of  scrofula  can  be 
discovered,  it  is  probable  that  the  tumour  will  be  of  scrofulous 
origin.  It  is  impossible  at  present  to  enter  upon  the  wide 
subject  of  the  diagnosis  of  syphilitic  affections  of  the  nervous 
system  further  than  to  warn  the  student  of  the  extreme  import- 
ance of  the  subject;  for  inasmuch  as  there  is  no  severe  organic 
disease  affecting  the  nervous  system  in  which  the  results  of 
treatment  are  so  often  satisfactory,  so  there  is  no  disease  which 


294  GENERAL   DIAGNOSIS  AND  PROGNOSIS. 

deservedly  brings  so  much  discredit  upon  the  practitioner  who 
overlooks  its  presence. 

The  causes  of  disease,  both  exciting  and  predisposing,  afford 
valuable  aid  in  diagnosis,  A  history  of  the  patient  having 
been  exposed  to  excessive  fatigue,  cold,  or  traumatic  influences, 
or  having  recently  suffered  from  an  attack  of  one  of  the  acute 
specific  fevers,  including  diphtheria,  or  evidence  which  would 
lead  to  the  suspicion  of  some  poison  having  been  taken,  may 
afford  valuable  information  to  aid  us  in  forming  a  correct 
diagnosis. 

(II.)-PEOGNOSIS. 

§  135.  It  may  be  stated  as  a  general  law  that,  other  things 
being  equal,  the  prognosis  is  more  favourable  in  affections  of  the 
sensory  than  of  the  motor  mechanism.  We  have  already  seen 
that  the  efferent  impulses  pass  through  much  more  definite 
channels  than  the  afferent  impulses.  The  voluntary  efferent 
impulses  issue  from  large  caudate  cells  in  the  cortex  of  the 
brain,  pass  downwards  through  distinct  medullated  nerve  fibres, 
to  reach  the  large  ganglion  cells  of  the  anterior  grey  horns  of 
the  spinal  cord,  the  latter  being  connected  by  distinct  axis- 
cylinder  processes  with  the  efferent  fibres  of  the  peripheral 
nerves.  The  structure  of  the  sensory  presents  a  striking  con- 
trast to  that  of  the  motor  mechanism.  It  is  true  that '  afferent 
currents  from  the  periphery  are  conveyed  by  medullated  fibres 
to  the  spinal  cord  through  the  posterior  roots ;  but  these  fibres 
are  smaller  in  diameter  than  the  corresponding  fibres  of  the 
anterior  roots,  and  on  reaching  the  grey  substance  they  do  not 
appear  to  form  any  definite  connections  with  the  cells  of  the 
posterior  horns,  nor  do  they  appear  to  be  continued  upwards 
uninterruptedly  through  the  cord  to  the  cortex  of  the  brain.  It 
seems  indeed  as  if  the  sensory  conduction  through  the  cord  were 
largely  effected  by  the  grey  substance,  and  in  a  diffused  manner. 
And  when  the  afferent  fibres  of  the  corona  radiata  reach  the 
cortex  of  the  brain,  instead  of  terminating  by  definite  connec- 
tions with  the  caudate  cells  of  the  internal  layers  of  the  cortex, 
they  are  continued  upwards  to  the  small  cells  of  the  superficial 
layers,  amongst  which  they  terminate,  but  without  forming  any 
definite  connections  with  them.     The  definite  structure  of  the 


GENEKAL   DIAGNOSIS  AND  PEOGNOSIS.  295- 

motor  mechanism  would,  therefore,  lead  us  to  expect  that  when 
any  of  its  fibres  and  cells  are  destroyed  a  more  or  less  enduring 
loss  of  conduction  and  paralysis  will  result ;  while  the  indefinite 
structure  of  the  sensory  mechanism  would  lead  us  to  expect 
that  when  some  of  its  cells  and  fibres  are  destroyed  the  afferent 
impulses,  temporarily  arrested,  will  readily  find  new  channels  of 
conduction  in  the  neighbouring  cells  and  fibres.  This  expecta- 
tion is  realised  in  practice.  Disease  or  injury  of  the  motor 
mechanism  is  known  to  produce  much  more  definite  and 
enduring  symptoms  than  disease  of  the  sensory  mechanism.         . 

In  the  spinal  cord  in  animals,  for  instance,  experimental  section 
of  the  lateral  column  produces  complete  paralysis  of  the  posterior 
extremity  of  the  same  side  ;  while  complete  loss  of  sensation  of 
the  posterior  extremities  does  not  result  so  long  as  a  small  portion 
of  the  grey  substance  of  the  cord  is  left  intact.  It  is  evident, 
therefore,  that  sensory  conduction  is  much  more  diffused  than 
motor  conduction.  Even  in  peripheral  paralysis  of  traumatic 
origin,  when  regeneration  of  the  nerve  takes  place,  sensibility 
reappears  in  the  affected  parts  at  a  much  earlier  period  than 
motor  power.,  This  fact  has  led  BaerwinkeP  to  propose  a  valu- 
able prognostic  test  in  cases  of  severe  traumatic  paralysis.  If  in 
the  first  few  months  after  injury  pressure  on  the  nerve  below  the 
seat  of  the  lesion  is  followed  by  an  eccentric  sensation,  it  may  be 
expected  that  regeneration  will  take  place,  and  that  motor  power 
will  subsequently  return. 

It  may  also  be  laid  down  as  a  general  law,  requiring  numerous 
qualifications,  that,  other  things  being  equal,  peripheral  are  less 
serious  than  central  affections,  and  cerebral  less  serious  than 
spinal  affections.  In  the  spinal  cord  the  centres  and  conducting 
paths  occupy  so  small  a  space  transversely  that  a  comparatively 
slight  lesion  may  injure  it  irretrievably;  while  the  brain  maybe 
the  seat  of  relatively  large  lesions,  without  any  definite  symptoms 
being  produced. 

The  prognosis  in  a  particular  case  often  depends  to  a  large 
extent  upon  the  cause  of  the  affection.  In  the  rheumatic,  toxic, 
syphilitic,  and  hysterical  affections,  and  in  those  which  occur 
after  diphtheria  and  other  acute  diseases,  the  prognosis  is  on  the 

^  Baerwinkel.  Ueber  ein  prognostisch  wichtiges  Symptom  traumatischer  Lah- 
mungen.    Arch.  f.  Heilkunde,  Bd.  XII.,  1871,  p.  336. 


296  GENERAL   DIAGNOSIS  AND  PROGNOSIS. 

whole  favourable.  The  prognosis  in  heemorrhage  depends  upon 
its  extent  and  the  locality  of  the  lesion.  Hemorrhage  into  the 
substance  of  the  spinal  cord,  unless  it  be  very  limited,  is  most 
unfavourable;  while  cerebral  haemorrhage,  unless  of  large  extent, 
is  favourable  so  far  as  partial  recovery  is  concerned.  Almost 
complete  restitution  of  the  functions  may  take  place  provided 
the  fibres  of  the  motor  tract  are  uninjured  ;  but  rupture  of  these 
fibres  is  followed  by  descending  changes  in  the  pyramidal  tract 
and  permanent  paralysis  with  contracture  of  the  affected  extre- 
mities. The  prognosis  in  cases  of  embolism  and  thrombosis 
depends  upon  the  size  of  the  vessel  obstructed,  upon  whether 
collateral  circulation  can  be  readily  established  or  not,  and  upon 
the  functional  importance  of  the  part  to  which  the  vessel  is 
distributed,  obstruction  of  the  vessels  supplying  the  motor 
mechanism  giving  rise  to  more  definite  and  permanent  symp- 
toms than  obstruction  of  the  vessels  of  other  parts. 

Very  little  can  be  said  with  regard  to  prognosis  in  inflammatory 
affections  of  the  nervous  system.  Acute  and  severe  inflammatory 
attacks  are  often  either  fatal  or  give  rise  to  incurable  symptoms. 
The  prognosis  in  subacute  inflammations  is  often  favourable ; 
while  that  of  the  chronic  inflammations  and  degenerations  is 
always  unfavourable  so  far  as  complete  restitution  is  concerned, 
although  they  may  extend  over  a  long  lifetime  without  producing 
symptoms  which  endanger  life.  Inflammation  of  grey  matter  is 
probably  more  immediately  dangerous  to  life  than  that  of  the 
white  substance  ;  but  if  the  danger  of  the  primary  symptoms  is 
overcome  the  probability  of  ultimate  recovery  is  much  greater  in 
the  former  than  in  the  latter.  Acute  inflammations  of  the  central 
grey  substance  of  the  spinal  cord  are  almost  uniformly  fatal;  but 
the  prognosis  is  by  no  means  unfavourable  in  subacute  inflam- 
mations. And  although  inflammation  of  the  white  substance  of 
the  cord  is  not  so  immediately  dangerous  to  life,  the  probability 
of  complete  recovery  is  less  than  with  inflammation  of  the  grey 
substance.  When  the  pyramidal  tract  is  injured  either  in  the 
cord  or  in  its  course  through  the  brain  the  probability  of  com- 
plete recovery  is  small.  A  certain  amount  of  degeneration  of 
the  tract,  or  loss  of  conduction  through  it  from  compression,  may 
be  recovered  from  ;  but  when  some  of  its  fibres  are  completely 
ruptured  by  a  neighbouring  haemorrhage  or  other  cause,  or  when 


GENERAL  DIAGNOSIS  AND   PROGNOSIS.  297 

degeneration  of  the  fibres  has  lasted  a  considerable  time,  com- 
plete recovery  from  the  paralytic  symptoms  must  not  be  ex- 
pected. When,  therefore,  the  paralysed  muscles  are  for  some 
little  time  the  subjects  of  muscular  tension,  contractures,  and 
exaggeration  of  the  deep  reflexes,  complete  restitution  is  im- 
possible. 

In  the  atrophic  forms  of  paralysis,  whether  of  spinal  or  peri- 
pheral origin,  much  valuable  aid  in  forming  a  prognosis  is 
obtained  from  electrical  examination  of  the  affected  muscles. 
If  the  faradic  and  galvanic  contractility  of  the  muscles  is  very 
slightly  diminished  without  any  qualitative  changes,  recovery 
will  be  rapid.  Even  when  the  "reaction  of  degeneration"  is 
present,  and  the  faradic  contractility  of  the  affected  muscles  is 
abolished  for  a  time,  if  slight  voluntary  movement  and  faradic 
contractility  reappear  at  the  end  of  six  weeks  from  the  onset  of 
the  affection,  recovery  will  be  comparatively  rapid.  If,  however, 
slight  motor  power  and  the  faradic  contractility  do  not  reappear 
until  the  thirtieth  week  from  the  onset  of  the  disease,  recovery 
will  be  very  slow  (extending  over  a  period  of  twelve  months), 
and  often  imperfect.  When  every  trace  of  both  faradic  and  gal- 
vanic irritability  has  disappeared  from  the  muscle,  recovery  is  no 
longer  possible. 

The  prognosis  in  paralysis  of  whatever  kind  becomes  more 
grave  when  it  is  accompanied  by  well-marked  anaesthesia  and 
by  decided  vaso-motor  and  trophic  disturbances,  especially  by 
extensive  and  sloughing  bed-sores.  In  spinal  paralysis  the  prog- 
nosis becomes  very  grave  when  the  sphincter  of  the  bladder  and 
rectum  become  paralysed,  and  when  the  urine  is  alkaline  and 
foetid  and  contains  pus ;  while  commencing  paralysis  of  the 
muscles  of  respiration  and  of  deglutition  indicates  impending 
dissolution. 


298 


CHAPTER   IX. 


GENERAL    TREATMENT. 

In  the  management  of  nervous  diseases  the  organism,  as  a 
whole,  must  be  subjected  to  treatment.  Consequently  the  rules 
to  be  observed  in  the  treatment  of  the  nervous  system  are 
essentially  the  same  as  those  which  experience  has  proved  to  be 
useful  in  the  treatment  of  diseases  of  other  tissues  and  organs 
of  the  body.  It  is  therefore  unnecessary  to  describe,  in  detail, 
the  principles  which  ought  to  guide  us  in  the  treatment  of 
diseases  of  the  nervous  system. 

The  treatment  of  the  nervous  system  may  be  divided  into 
that  which  is  directed :  (1)  to  prevent  disease  (prophylactic)  ; 
(2)  to  remove  the  exciting  cause  of  the  disease ;  (3)  to  remove 
the  anatomical  cause ;  and  ( 4 )  to  allay  or  remove  serious 
symptoms. 

§  136.  (1)  Prophylaxis. — The  prophylactic  treatment  of 
disease  may,  to  some  extent,  be  regarded  as  part  of  general 
hygiene.  It  consists,  indeed,  of  a  special  application  of  hygienic 
rules  to  the  cases  of  those  who  manifest  inherited  or  acquired 
proclivities  to  certain  diseases  of  the  nervous  system.  A  young 
lady,  for  instance,  whose  mother  has  suffered  from  severe  trige- 
minal or  other  form  of  neuralgia,  should  be  specially  cared  for, 
and  protected  from  mental  excitement  and  unnecessary  exposure 
to  cold,  at  the  period  of  sexual  development,  when  neuralgia  is 
so  apt  to  become  established  for  the  first  time.  The  children  of 
parents  who  manifest  a  predisposition  to  severe  nervous  disease, 
as  hysteria  and  epilepsy,  are  frequently,  not  merely  quick  in  their 
perceptive  faculties,  but  are  also  often  possessed  of  great  intel- 
lectual powers,  and  much   of  their  future   happiness  depends 


GENERAL   TREATMENT.  299 

upon  judicious  mental  training  in  youth.  Even  the  children  of 
families,  some  members  of  which  have  suffered  from  the  graver 
psychoses,  are  no  exceptions  to  this  rule,  as  it  is  notorious  how 
often  "  genius  to  madness  is  allied."  The  children  of  such  fami- 
lies ought  not  to  be  subjected  to  any  severe  mental  strain  during 
the  period  of  bodily  development,  or  allowed  to  enter  into  com- 
petition with  other  children  in  the  mental  gymnastics  which  are 
so  fashionable  at  our  public  schools.  On  the  other  hand,  regular, 
graduated,  and  systematic  exercise,  in  the  form  of  walking, 
riding,  gymnastics,  and  calisthenics,  does  a  great  deal  of  good 
by  strengthening  both  the  muscular  and  nervous  systems. 
Everything  which  tends  to  develop  the  muscles  of  the  lower 
extremities  and  trunk,  and,  indeed,  all  muscles  engaged  in 
executing  the  movements  common  to  both  man  and  the  lower 
animals,  tends  also  to  develop  the  fundamental  part  of  the 
nervous  system ;  and  a  good  sound  development  of  the  funda- 
mental is  the  first  pre-requisite  to  a  well-balanced  development 
of  the  accessory  portion. 

The  order  of  the  development  of  the  nervous  system  in  the 
race  has  been  from  the  fundamental  to  the  accessory  portions, 
and  no  one  can  reverse  this  process  with  impunity  in  that  fur- 
ther development  of  the  individual  which  constitutes  education 
in  its  widest  sense.  Yet  until  a  few  years  ago  the  natural  order 
of  development  was  reversed  in  the  education  of  youth,  and 
especially  in  female  education,  so  far  as  this  could  be  accom- 
plished by  human  contrivance  and  ingenuity.  The  natural  order 
of  development  was  indeed  observed  so  far  as  to  allow  the  child 
to  acquire  the  power  of  walking  prior  to  that  of  other  accom- 
plishments, but  the  care  of  the  infant  had  not  yet  been  transferred 
to  the  professional  trainer.  No  sooner,  however,  had  what  is 
technically  called  education  begun  than  the  professional  trainer 
began  to  exercise  the  small  muscles  of  vocalisation  and  articula- 
tion so  as  to  acquire  the  art  of  reading,  the  small  muscles  of  the 
hand  so  as  to  acquire  the  art  of  writing,  and  in  the  case  of  young 
ladies  the  still  more  complicated  movements  necessary  in  running 
over  the  key -board  of  a  piano  ;  while  little  attention  was  paid  to 
the  development  of  the  larger  muscles  of  the  trunk  and  lower 
extremities  upon  the  full  development  of  which  the  future  health 
and  comfort  of  the  individual  depends. 


300  GENERAL   TREATMENT. 

In  the  education  of  youth,  in  the  present  day,  the  lavv^s  of 
development   and   physiology  are   not   so   openly  violated  and 
defied  as  they  were  a  few  years  ago ;  but  much  yet  remaias  to 
be  done  in  this  respect,  and  especially  in  the  education  of  the 
children  of  families  who  manifest  a  neuropathic  tendency.     In 
the  children  of  such  families  the  greatest  possible  care  should  be 
taken  to  develop  carefully  the  fundamental  actions,  inasmuch  as 
a  sound  development  of  these  involves  a  stable  construction  of 
the  fundamental  part  of  the  nervous  system,  a  process  which 
enables  the   latter  to   offer  greater   specific   resistance  to  the 
paroxysmal   discharges  from  the  later  evolved  centres  of  the 
accessory  portion  which  underlie  hysteria,  epilepsy,  and  even 
many  of  the  psychoses.     The  process  of  educating  the  accessory 
system,  and  especially  the  higher  centres  of  that  system  in  young 
people  with  a  neuropathic  predisposition,  should  be  regular  and 
systematic;    habits   of   mental   scrutiny   and   self-examination, 
which,  unfortunately,  too  many  religious  teachers  deem  necessary 
for  the  welfare  of  the  soul,  ought  to  be  discouraged.     In  one 
word,  education  should  be  made  as  concrete  and  objective  as 
possible.     By  such  training  it  is  not  only  possible  to  gain  access 
to  the  highest  treasures  of  the  intellect,  to  poetry,  music,  and 
art,  but  such  training  can  also  be  made  subservient  to  the  due 
development  of  the  religious  sentiments.     Sentimental  novels, 
with  harrowing  descriptions  of  lacerated  feeling  and  wounded 
vanity,  are  to  be  utterly  proscribed ;   but  novels  like  those  of 
Scott,  which  lead  the  mind  outwards  to  contemplate  natural 
scenery,  historical  incidents,  and  the  manners  and  mode  of  living 
of  a  past  age,  are  really  useful  educational  adjuncts.^     Fatigue, 
late  hours,  undue  excitement  from  theatres  and  balls,  or  from 
the  use  of  alcoholic  stimulants,  and  every  other  means  by  which 
the  nervous  energy  is  exhausted,  ought  to  be  carefully  avoided. 
It  is  during  sleep  that  the  used-up  energies  of  the  nervous 
system  are  chiefly  restored,  and  consequently  those  who  have  a 
neurotic  tendency,  especially  during  the  period  of  active  bodily 
and  sexual  development,  should  sleep  not  less  than  ten  out  of  the 
twenty-four  hours.    Sleeplessness  is  itself  a  disease,  and  sleepless- 
ness, without  obvious  cause,  is  frequently  the  forerunner  of  one 

1  See  Anstie  (F.  E.).    Neuralgia  and  the  Diseases  that  resemble  it.    Lond.,  1871. 
pp.  123  and  212. 


GENEEAL  TREATMENT.  301 

of  the  graver  psychoses.  It  ought  to  be  mentioned  that  young 
people  with  a  neuropathic  predisposition  are  peculiarly  liable  to 
indulge  in  sexual  excess ;  and  their  guardians  should,  therefore, 
be  specially  on  the  alert  lest  they  indulge  in  the  practice  of 
onanism,  which  exercises  a  most  deleterious  influence  on  the 
nervous  system,  both  strongly  predisposing  to  various  diseases, 
and  acting  as  a  powerful  exciting  cause  of  grave  nervous 
disease. 

It  is  scarcely  necessary  to  add  that  those  who  inherit  a  pre- 
disposition to  nervous  diseases  require,  in  addition  to  exercise, 
careful*  regulation  of  diet  and  a  due  exposure  to  sunlight  and 
fresh  air.  In  many  cases  the  administration  of  iron  and  cod 
liver  oil  is  attended  with  the  most  beneficial  results ;  in  one 
word,  the  standard  of  the  health  must  be  maintained  at  its 
highest  point  of  efficiency,  and  this  can  be  done,  not  by  treating 
the  nervous  system,  but  by  treating  the  organism  as  a  whole. 

§  137.  (2)  Removal  of  the  Exciting  Cause. — The  next  indica- 
tion of  treatment  is  to  remove  the  exciting  cause  of  the  disease, 
and  it  is  quite  unnecessary  to  say  much  at  present  on  this 
subject.  If  the  disease  has  been  induced  by  unfavourable  con- 
ditions of  climate,  exposure  to  variations  of  temperature,  and 
excessive  fatigue,  these  conditions  must  be  obviated.  When  the 
affection  has  been  caused  by  wounds  and  contusions  of  the 
nervous  tissues,  or  by  compression,  as  by  the  gradual  growth  of 
tumours,  the  exciting  causes  must  be  removed  by  surgical  inter- 
ference, and  the  damage  done  to  the  tissues  treated  according  to 
general  surgical  principles. 

If  the  disease  is  caused  by  a  morbid  poison,  as  syphilis,  malaria, 
gout,  rheumatism,  and  the  metallic  poisons,  the  treatment  must 
be  first  directed  to  remove  these  poisons  from  the  system  or  to 
neutralise  their  action.  Syphilitic  disease  of  the  nervous  system 
occurs  in  so  many  forms  that  it  may  be  said  to  simulate  almost 
every  form  of  grave  nervous  disease.  But  whatever  may  be  the 
form  in  which  it  appears,  the  same  general  treatment  must  be 
adopted  as  for  syphilis  of  other  tissues  and  organs.  It  must  be 
remembered,  however,  that  syphilitic  disease  of  the  nervous 
system  usually  belongs  to  the  late  or  tertiary  symptoms  of  the 
affection,    and   consequently  the   treatment   must   be   modified 


802  GENEEAL  TREATMENT. 

accordingly.  Syphilis  of  the  nervous  system,  as  a  rule,  demands 
large  doses  of  the  iodide  of  potassium,  not  less  than  from  a 
scruple  to  half  a  drachm  three  times  a  day ;  and  if  this  fail  to 
give  relief,  from  one-twelfth  to  one-eighth  of  a  grain  of  the 
bichloride  of  mercury  may  be  given  three  times  a  day. 

In  neuralgia  and  other  diseases  of  malarial  origin  quinine 
and  arsenic  are  the  best  known  and  most  reliable  remedies.  In 
nervous  diseases  of  gouty  origin  a  moderate  dose  of  colchicum 
along  with  a  saline  aperient  is  useful ;  while  rheumatic  neuroses 
are  benefited  by  salicylic  acid,  local  fomentations,  and  vapour 
baths ;  and  chronic  affections,  by  the  use  of  iodide  of  potassium 
and  guaiacum. 

In  acute  poisoning  a  drug  may  at  times  be  administered 
whose  action  counteracts  that  of  the  first  agent.  Atropine,  for 
example,  appears  to  arrest  to  some  extent  the  poisonous  action 
of  opium,  chloral  that  of  strychnine,  and  this  list  might  be 
indefinitely  extended  ;  but  the  practical  results  which  have  been 
obtained  from  the  administration  of  the  so-called  antidotes  have 
never  realised  the  high  expectations  at  one  time  formed  of  their 
utility. 

§  138.  (3)  Removal  of  the  Anatowiical  Cause. — The  anato- 
mical cause  of  diseases  of  the  nervous  system  must  be  removed 
by  favourably  influencing  the  nutrition  of  the  diseased  part,  no 
matter  whether  the  lesion  be  molar  or  molecular.  The  nutrition 
of  the  nervous  system  as  a  whole  and  of  its  various  parts  may 
be  influenced  in  various  ways.  Nutritive  changes  may  be  pro- 
duced by  agents  which  act  directly  on  the  nervous  tissues 
themselves,  the  connective  tissues  surrounding  the  nervous  ele- 
ments including  the  lymph  spaces,  the  blood-vessels  including 
their  vaso-motor  nerves  and  centres,  or  the  blood.  The  agents 
which  act  on  each  of  these  tissues  may  in  practice  be  variously 
combined  ;  so  that  the  methods  by  which  the  nutrition  of  any 
part  of  the  nervous  system  may  be  influenced  are  almost  in- 
numerable. We  shall  not  attempt  any  elaborate  classification 
of  the  remedial  agents  comprised  in  this  division  further  than 
is  implied  in  an  orderly  enumeration  of  some  of  the  more  im- 
portant of  them,  but  shall  found  our  confidence  in  them  almost 
entirely  on  empirical  observation. 


GENERAL   TREATMENT.  303 

The  agents  comprised  in  this  subdivision  may  be  subdivided 
into :  (A)  Internal  Remedies,  (B)  External  E,emedies  ; — 

(A)  INTERNAL  REMEDIES. 
Internal  remedies  are  those  which  act  after  being  absorbed 
into  the  blood,  no  matter  whether  they  are  absorbed  through 
the  stomach,  the  skin,  after  subcutaneous  injection,  or  are 
directly  injected  into  a  vein.  The  following  are  some  of  the 
remedies  of  this  class  which  are  most  employed  in  the  treat- 
ment of  the  diseases  of  the  nervous  system. 

§  139.  Strychnine,  and  the  preparations  of  nux  vomica,  in- 
crease the  irritability  of  the  grey  substance  of  the  spinal  cord 
and  consequently  diminish  its  resistance,  and  they  are  usefully 
administered  when  the  spinal  irritability  is  depressed.  These 
agents  produce  the  most  favourable  effect  in  cases  of  muscular 
weakness  unattended  by  organic  lesion.  Their  administration  is 
attended  probably  witb  more  benefit  in  the  visceral  than  in  the 
external  akineses ;  they  are  powerful  remedies  in  atonic  dyspepsia, 
constipation  with  flatulence,  paralysis  of  the  sphincters,  nocturnal 
incontinence  of  urine,  sexual  debility ;  and  Dr.  Milner  Fothergill 
has  strongly  advocated  the  administration  of  strychnine  as  a 
stimulant  of  the  respiratory  centres  in  cases  of  emphysema  and 
bronchitis.  Strychnia  is  not,  however,  an  agent  of  much  value 
in  the  treatment  of  nervous  diseases  depending  upon  structural 
change.  In  all  acute  affections  of  the  nervous  system  it  is 
positively  injurious ;  while  in  the  chronic  organic  diseases  it  is 
almost  valueless. 

Gonium  acts  in  some  respects  in  an  opposite  way  to  strychnine 
by  depressing  the  reflex  irritability  of  the  cord.  The  investiga- 
tions of  Drs.  Crum  Brown  and  Fraser  prove  that  the  alkaloid 
conia  produces  paralysis  solely  by  influencing  the  motor  nerves, 
and  is  in  this  respect  analagous  in  its  action  to  curara.  They 
have,  however,  shown  that  some  of  the  methyl  compounds  of 
conia  depress  the  irritability  of  both  the  motor  nerves  and  of  the 
spinal  cord.  These  authors  have  likewise  found  that  commercial 
specimens  of  conia  are  a  mixture  in  variable  proportions  of  conia 
and  methyl-conia,  and  that  the  succus  conii  of  the  Pharmacopoeia 
also  contains  methyl  compounds  of  conia ;  so  that  conia  as  usually 


804  GENERAL   TREATMENT. 

administered  depresses  the  irritability  of  the  spinal  cord,  although 
the  pure  alkaloid  only  acts  on  the  motor  nerves,  Conia  has  been 
administered  successfully  in  cases  of  tetanus,  but  it  is  probable 
that  the  beneficial  results  which  followed  its  administration  were 
due  to  the  impurity  of  the  drug,  and  that  more  reliable  results 
would  be  obtained  by  the  use  of  hydrochlorate  of  methyl-conia. 
Conia  does  not  appear  to  exercise  any  influence  on  the  action  of 
the  heart.  Dr.  Crichton  Browne^  strongly  recommends  conium 
in  acute  mania,  and,  whatever  may  be  its  mode  of  operation, 
experience  shows  that  it  is  a  powerful  agent  in  allaying  excite- 
ment under  such  circumstances. 

§  140.  Calabar  Bean  gradually  lessens  and  ultimately  destroys 
the  irritability  of  the  grey  substance  of  the  cord,  causing  anes- 
thesia, loss  of  reflex  excitability,  and  paralysis.  Its  action  is 
therefore  more  directly  opposed  to  that  of  strychnine  than  that 
of  methyl-conia.  Calabar  bean,  or  its  alkaloid  physostigma,  may 
therefore  be  administered  in  cases  of  increased  irritability  of  the 
grey  substance  of  the  cord ;  such  as  that  which  occurs  during 
strychnine  poisoning,  and  this  agent  has  been  successfully  em- 
ployed in  the  treatment  of  tetanus  (Watson,  Einger).  Physos- 
tigma diminishes  the  number  of  the  heart's  contractions,  but 
lessens  the  duration  of  each  systole,  and  at  last  the  heart  ceases 
to  beat  in  diastole.  During  this  action  a  weaker  electric  current 
through  the  vagus  is  required  to  arrest  the  action  of  the  heart 
than  in  health,  and  if  the  ends  of  the  pneumogastric  nerves  are 
poisoned  by  atropia,  physostigma  will  restore  the  action  of  the 
paralysed  nerve;  hence  it  has  been  concluded  that  this  drug 
increases  the  irritability  of  the  terminal  fibres  of  the  pneumo- 
gastric nerve.  This  agent  is  also  a  respiratory  poison,  and 
generally  kills  by  paralysing  the  respiration. 

§  141.  Atropine,  or  Belladonna,  is  a  powerful  agent  in  the 
treatment  of  many  diseases  of  the  nervous  system.  The  following 
is  a  brief  summary  of  the  actions  of  atropia.  It  increases  the 
irritability  of  the  grey  substa*nce  of  the  spinal  cord,  acting 
specially  on  the  respiratory  and  vaso-motor  centres,  and  also 
stimulates    the    cardiac    acceleratory    nerve   or   its   centre.     It 

1  Lancet,  Vol.  L,  1872,  pp.  143,  182,  217. 


GENERAL   TREATMENT.  305 

paralyses  the  motor  nerves,  first  affecting  those  of  the  trunk,  the 
terminations  of  the  vagi  both  in  the  heart  and  lungs,  the  termi- 
nations of  the  secretory  nerves  of  the  salivary  glands  and  of  the 
sweat  glands,  the  terminations  of  the  inhibitory  fibres  of  the 
splanchnics,  and  the  terminations  of  the  nerves  supplying  the  iris. 
It  appears  also  to  stimulate  the  pupillary  fibres  of  the  sympathetic 
nerves  to  the  eyes.  In  large  doses  it  depresses  the  functions  of 
the  afferent  nerves.  The  therapeutic  uses  of  belladonna  are  so 
manifold  that  we  can  only  mention  a  few  of  them  at  present. 
This  drug  has  been  found  useful  in  checking  profuse  sweating, 
especially  the  night  sweats  of  phthisis ;  and  the  secretion  of 
milk.  It  is  also  very  useful  in  habitual  constipation,  and  has 
been  recommended  by  Harley'^  as  a  cardiac  tonic.  Bella- 
donna is  exceedingly  useful  in  allaying  the  paroxysmal  cough  of 
whooping  cough,  and  probably  also  diminishes  secretion  in  cases 
of  chronic  bronchial  catarrh.  It  is  one  of  the  best  remedies  in 
cases  of  incontinence  of  urine,  and,  combined  with  zinc,  it  is 
often  a  successful  remedy  in  cases  of  nocturnal  emissions  (Ringer). 
Its  use  was  recommended  by  Dr.  Brown-Sequard^  in  the  treat- 
ment of  paralysis  depending  upon  chronic  inflammation  of  the 
spinal  cord,  on  the  supposition  that  it  produces  contraction  of 
the  arterioles  of  the  cord,  and  thus  diminishes  the  supply  of  blood 
to  it.  Belladonna  is,  no  doubt,  useful  at  times  in  the  treatment 
of  chronic  spinal  affections,  but  it  is  doubtful  how  far  the  theory 
upon  which  this  treatment  was  originally  founded  is  correct. 
Belladonna  has  also  been  found  useful  in  the  treatment  of 
epilepsy.  In  addition  to  its  action  on  the  spinal  cord  and 
peripheral  nerves,  belladonna  also  acts  on  the  brain.  The  first 
effect  is  stimulant,  giving  rise  to  a  rapid  but  connected  succession 
of  ideas,  but  the  ideas  soon  become  extravagant  and  incoherent, 
and  a  busy  delirium  sets  in  accompanied  by  pleasing  illusions. 
The  delirium  may  at  times  be  furious  and  dangerous,  so  that  the 
patient  requires  to  be  placed  under  restraint.  Its  action  on  the 
cerebrum  renders  belladonna  a  valuable  agent  in  allaying  pain. 

§  142,  Ergot  is  supposed  by  Brown-Sdquard^  to  produce  con- 

i^Harley.     On  the  action  and  uses  of  belladonna.     Braithwaite's  Retrospect, 
Vol.  L VII.,  1868,  p.  386. 

'^  Brown-Sequard.    Lancet.    Vol.  II.,  1860,  p.  605,  '' Ihid. 

VOL.  L  U 


306  GENEEAL   TREATMENT. 

traction  of  the  blood-vessels  of  the  spinal  cord  and  its  mem- 
branes, and  he  recommends  it  to  be  given  in  cases  of  paraplegia 
with  irritation  of  motor,  sensitive,  or  vaso-motor  nerves. 

§  143.  Opium  lessens  the  irritability  of  the  sensory  conducting 
paths  and  of  the  perceptive  centres.  Small  doses  first  increase 
the  irritability,  but  the  primary  increase  is  soon  followed  by  a 
secondary  stage  of  depression,  and  if  a  large  dose  be  adminis- 
tered the  first  stage  of  increased  irritability  is  so  transitory  that 
it  may  be  entirely  overlooked,  Bernard  concluded  that  opium 
also  depresses  the  irritability  of  the  sympathetic  system,  and 
especially  the  part  supplying  the  submaxillary  gland.  Opium 
may  be  administered,  like  all  agents  of  this  class,  in  small  doses, 
with  the  view  of  obtaining  its  primary  or  stimulant  action,  and 
in  large  doses  so  as  to  obtain  its  secondary  or  sedative  action.  In 
small  doses  it  is  found  useful  whenever  the  irritability  of  the 
nervous  system  is  depressed,  especially  during  times  of  nervous 
exhaustion  produced  by  anxiety  and  overwork.  In  larger  doses 
this  drug  is  found  useful  whenever  the  irritability  of  the  sensory 
mechanism  is  increased.  Opium  and  its  alkaloids  are  indeed  the 
most  powerful  agents  we  possess  for  allaying  pain  and  procuring 
sleep,  and  are  therefore  our  most  generally  useful  aids  in  removing 
the  most  distressing  symptoms  of  nervous  diseases. 

§  144.  Hydrate  of  Chloral  in  moderate  doses  induces  sleep, 
and  in  large  doses  profound  coma.  Both  sensation  and  reflex 
action  is  diminished  under  its  action,  and  death  is  caused  by 
arrest  of  respiration  or  paralysis  of  the  heart.  Dr.  Hammond 
suggested  that  the  action  of  chloral  is  due  to  anaemia  of  the 
cerebral  substance,  caused  by  vaso-motor  contraction  of  the 
vessels  of  the  brain,  but  it  is  much  more  probable  that  chloral, 
as  well  as  chloroform,  ether,  and  the  other  agents  which  are 
called  ansesthetics,  act  directly  on  the  nervous  tissues  them- 
selves.. All  these  agents  have,  like  opium,  a  primary  stimulant, 
followed  by  a  secondary  sedative  action.  They  appear,  indeed, 
to  act  as  poisons  to  any  living  protoplasm,  although  the  pheno- 
mena produced  by  arrest  of  the  special  functions  of  the  nervous 
tissues  become  so  marked  and  predominant  as  to  obscure  the 
effect  on  the  protoplasm  of  the  other  tissues. 


GENERAL  TREATMENT.  307 

When  the  agents  which  are  classed  as  anaesthetics  are  intro- 
duced into  the  circulation,  the  rapidity  with  which  each  will 
reach  the  protoplasm  of  the  tissues  depends  on  the  degree  of 
diffusibility  of  the  drug,  the  activity  of  the  circulation  in  a  part, 
and  the  density  of  the  cell  walls  and  intercellular  substance  of 
the  tissues.  The  more  diffusible  the  agent  the  sooner  it  gains 
access  to  the  tissues,  and  the  sooner  it  is  eliminated,  hence  the 
greater  the  diffusibility  ,of  the  agent  the  sooner  is  the  action  pro- 
duced, but  the  more  transitory  will  the  action  be.  Those  tissues 
which  are  supplied  with  a  large  quantity  of  blood  will  also  have 
a  relatively  large  quantity  of  the  drug  supplied  to  them,  hence 
the  active  tissues  will  be  affected  before  tlie  passive  tissues,  and 
the  grey  substance  of  the  brain  will  be  affected  in  preference  to 
the  white  substance.  The  protoplasm  of  the  tissues  which  are 
composed  of  small  cells  with  thin  cell-membranes  will  be  reached 
by  the  agent  in  a  shorter  time  and  in  a  larger  quantity  than  that 
of  tissues  consisting  of  large  cells  with  denser  cell-membranes, 
hence  the  small  cells  of  the  sensory  mechanism  will  be  affected 
in  preference  to  the  large  cells  of  the  motor  mechanism. 

Chloral  and  allied  agents  are  usually  administered  in  relatively 
large  doses  with  the  view  of  depressing  the  irritability  of  the 
sensory  mechanism  and  procuring  sleep.  Chloral  has  been  found 
useful  in  the  treatment  of  tetanus  and  of  strychnine  poisoning, 
and  as  a  sedative  and  hypnotic  in  cases  where  the  irritability  of 
the  sensory  mechanism  is  increased. 

§  145.  Bromide  of  Potassium  and  its  allies  depress  the  irri- 
tability of  the  brain  and  spinal  cord,  inducing  in  large  doses  a 
diminution  of  sensibility  and  of  reflex  excitability.  Its  action 
is,  indeed,  like  that  of  chloral,  but  the  action  of  the  latter 
is  more  prompt  and  mose  evanescent.  It  is  very  probable  that 
the  greater  atomic  weight  of  the  constituents  of  bromide  of 
potassium,  as  compared  with  those  of  chloral,  renders  the  elimi- 
nation of  the  former  from  the  body  more  slow  and  difficult  than 
that  of  the  latter.  The  bromide  of  potassium  also  appears  to 
lower  the  irritability  of  the  motor  mechanism,  while  chloral  acts 
more  exclusively  on  the  sensory  mechanism,  but  both  drugs 
seem  to  act  on  the  grey  centres  of  the  brain  and  spinal  cord  in 
preference  to  the  conducting  paths.     Bromide  of  potassium  is  a 


308  GENEEAL  TREATMENT. 

most  valuable  remedy  when  it  is  desired  to  depress  more  or  less 
permanently  the  irritability  of  these  grey  centres,  while  chloral 
is  the  better  remedy  when  a  prompt  but  temporary  action  is 
required.  Bromide  of  potassium  is  therefore  a  more  valuable 
remedy  than  chloral  in  hysteria  and  epilepsy,  and  in  various 
other  spasmodic  affections. 

§  146.  Iodide  of  Potassium  has  probably  no  special  actioD  on 
the  nervous  tissues  themselves,  but  its  well-known  action  in 
quickening  the  absorption  of  inflammatory  effusions  renders  it 
an  invaluable  agent  in  the  treatment  of  many  nervous  diseases. 
Its  use  in  syphilitic  nervous  affections  has  already  been  men- 
tioned. 

§  147.  Mercurial  Prejoarations  are  also  occasionally  useful  in 
the  treatment  of  inflammatory  diseases  of  the  nervous  system, 
more  especially  those  affecting  the  membraues  of  the  brain  and 
spinal  cord  and  the  sheaths  of  nerves ;  their  use  in  the  present 
day  is  in  a  great  measure  restricted  to  the  treatment  of  syphilitic 
nervous  diseases. 

§  148.  Zinc  and  its  preparations  belong  to  a  class  of  agents 
which  have  been  termed  "nervine  tonics,"  on  the  supposition 
that  they  promote  the  nutrition  of  the  nervous  system.  It  is 
probable  that  these  agents  enable  weakened  nervous  tissues  to 
absorb  a  larger  stock  of  nutriment  from  the  blood,  while  at  the 
same  time  the  molecules  of  these  materials  are  so  arranged  that 
greater  resistance  is  offered  to  change,  hence  external  stimula- 
tion does  not  give  rise  to  such  wide-spread  nervous  discharge, 
while  the  resulting  local  discharges  are  more  powerful  and  better 
co-ordinated.  But  it  will  suffice  for  us  to  know  at  present  that 
these  agents  are  proved  by  experience  to  exercise  a  favourable 
influence  on  the  nutrition  of  the  nervous  system.  Preparations 
of  zinc  have  been  successfully  used  in  the  treatment  of  chorea, 
epilepsy,  whooping-cough,  and  other  spasmodic  affections. 

§  149.  Arsenic  is,  according  to  Dr.  Ringer,  a  protoplasmic 
poison,  destroying  first  the  functional  activity  of  the  central 
nervous  system,  next  of  the  nerves,  and  last  of  the  muscles.   But 


GENERAL  TREATMENT.  809 

like  all  other  poisons  of  this  class,  it  is  probable  that  the  first 
effect  of  small  doses  is  to  stimulate  the  functional  activity  of 
protoplasm,  and  that  its  administration  in  regulated  doses  will 
be  beneficial  in  many  cases  of  nervous  debility.  It  has  been 
found  useful  in  some  chronic  diseases  of  the  spinal  cord,  and  is 
certainly  a  powerful  remedy  in  many  cases  of  neuralgia. 

§  150.  Pliospliorus  is  another  agent  which  has,  of  recent  years, 
been  strongly  recommended  in  the  treatment  of  various  nervous 
affections.  It  probably  acts  as  a  stimulant  to  the  nervous 
centres,  and  increases  the  nutritive  activity  of  nervous  tissues 
generally.  It  has  been  found  useful  in  functional  paralysis, 
chronic  alcoholism,  migraine,  and  in  many  forms  of  neuralgia. 

§  151.  Silver  salts  have  been  employed  in  the  treatment  of 
nervous  diseases.  Nitrate  of  silver  in  poisonous  doses  excites 
convulsions  in  animals,  and  these  are  followed  by  paralysis.  The 
convulsions  are  similar  to  those  produced  by  strychnia,  and  are 
excited  by  the  least  peripheral  irritation  (Ringer).  Both  the 
oxide  and  nitrate  have  been  employed  in  the  treatment  of  chorea 
and  epilepsy,  and  they  have  been  found  specially  useful  in  the 
treatment  of  locomotor  ataxy. 

§  152.  Quinia  is  one  of  the  most  generally  useful  nervine 
tonics.  Administered  in  large  doses  it  produces  noises  in  the 
ears,  and  occasionally  causes  deafness,  and  even  temporary 
blindness  may  be  produced.  It  also  causes  severe  dull  frontal 
headache,  and  in  poisonous  doses  abolishes  reflex  action  before 
voluntary  movement,  by  stimulation  of  Setschenow's  reflex  in- 
hibitory centre  (Ringer).  The  best  known  action  of  quinia  is 
that  by  which  it  arrests  attacks  of  ague,  but  it  is  equally  useful 
in  the  treatment  of  other  affections  of  malarial  origin.  Neuralgia 
is  especially  prone  to  arise  from  malaria,  and  against  this  form 
of  the  disease  quinia  is  a  specific.  But  quinia  is  also  useful  in 
other  forms  of  neuralgia,  especially  when  they  assume  a  periodic 
type,  as  frequently  happens  in  neuralgia  of  the  supra-orbital 
branch  of  the  fifth  nerve. 

§  153.  Milh,  whey,  and  grape  "  cures,"  as  well  as  courses  of 


810  GENERAL   TREATMENT. 

mineral  waters,  produce  a  beneficial  effect  on  diseases  of  the 
nervous  system,  in  so  far  as  they  exercise  a  favourable  influence 
on  the  nutrition  of  the  body  generally. 

(B)   EXTERNAL  REMEDIES. 

§  154,  Cold,  steadily  applied,  lowers  the  irritability  and 
retards  the  conductivity  of  the  nervous  tissues.  Riegel  and 
F.  Schultze  have  shown  that  the  spinal  cord  can  be  directly 
reached  by  the  application  of  cold,  but  the  experiments  of 
Dr.  Benham  appear  to  indicate  that  the  local  influence  on 
the  brain,  of  cold  steadily  applied  to  the  head,  is  not  great. 
Chapman's  vaso-motor  therapeutics  is  founded  on  the  assump- 
tion that  cold  applied  to  the  spine  lowers  the  irritability  of  the 
vaso-motor,  along  with  that  of  the  other  centres,  of  the  spinal 
cord,  and  thus  causes  dilatation  of  the  blood-vessels,  whose 
nervous  supply  issue  from  the  portion  of  the  cord  over  which 
the  cold  is  applied.  Chapman's  ice  bag  is  the  best  method  of 
applying  cold  to  the  spine ;  and  very  convenient  bags  are  also 
constructed  for  applying  ice  to  the  head,  or,  indeed,  to  any  part 
of  the  body. ' 

§  155,  Warmth  increases  the  irritability,  and  accelerates  the 
conductivity  of  the  nervous  tissues.  It  also  relaxes  the  tissues, 
especially  when  moisture  is  combined  with  warmth,  and  it  is 
probably  by  this  means  that  it  exercises  such  a  soothing  influ- 
ence in  painful  and  spasmodic  affections.  It  is  doubtful  whether 
warmth  directly  applied  over  the  head  and  spine  penetrates  to 
the  brain  and  spinal  cord,  but  warm  applications  are  often  very 
soothing  in  affections  of  these  organs,  the  action  being  probably 
produced  in  a  reflex  manner  through  the  cutaneous  nerves. 
Warmth  may  be  applied  by  means  of  hot  water  fomentations, 
poultices,  Priessnitz's  compresses,  hot  sand  bags,  or  caoutchouc 
bags  filled  with  hot  water. 

§  156.  Baths. — Cold  baths  tend  directly  to  lower  the  irritability 
of  the  nervous  tissues,  and  to  depress  the  nervous  functions,  and 
when  their  use  is  attended  with  benefit  it  is  due  to  their  indirect 
action.  The  first  apparent  effect  produced  by  a  cold  bath  is  to 
contract  the  cutaneous  blood-vessels,  but  whether  this  effect  is 


GENEKAL  TREATMENT.  311 

produced  by  a  reflex  stimulation  or  by  a  direct  action  on  the 
muscular  fibres  and  peripheral  terminations  of  the  nerves  is  not 
known.  Contraction  of  all  the  superficial  blood-vessels  is  followed 
by  a  sudden  rise  in  the  arterial  tension,  the  beat  of  the  heart 
becomes  more  powerful,  and  the  internal  organs,  including  the 
great  nervous  centres,  are  more  freely  supplied  with  blood.  The 
increase  in  the  supply  of  blood  to  the  ne^ve  centres  raises  their 
irritability,  so  that  more  powerful  nervous  discharges  are  sent 
out  to  the  various  organs,  including  the  heart,  rendering  its 
action  more  effective,  and  thus  increasing  still  further  the 
activity  of  the  circulation. 

However  efficient  the  cold  bath  may  be  as  a  means  of  treatment  in 
many  cases  of  nervous  debility  and  temporary  exhaustion,  it  is  manifest 
that  a  pre-requisite  to  the  success  and  safety  of  the  treatment  is  that  the 
patient  be  practically  free  from  any  organic  disease.  If,  for  instance,  the 
central  organ  of  the  circulation  be  enfeebled  from  any  cause,  the  sudden 
elevation  of  the  arterial  tension  may  arrest  its  action ;  if  the  walls  of  some 
or  all  of  the  blood-vessels  have  lost  their  elasticity  and  are  become  brittle 
from  degenerative  processes,  rupture  may  ensiie;  or  if  the  walls  of  the 
vessels  of  any  internal  organ,  and  especially  if  one  or  more  of  the  nervous 
centres,  are  enfeebled  by  local  inflammation  or  other  disease,  a  local  con- 
gestion may  be  caused  which  will  greatly  aggravate  the  affection.  The  cold 
bath  is,  however,  a  powerful  therapeutic  agent  in  the  numerous  functional 
diseases  to  which  the  nervous  system  is  liable ;  and,  notwithstanding  the 
drawbacks  and  limitations  which  have  just  been  described,  it  is  also,  with 
suitable  precautions,  useful  in  the  treatment  of  various  chronic  organic 
affections. 

§  157.  The  Sea  Bath  is  only  a  modification  of  the  cold  bath, 
but  several  factors  combine  to  make  the  action  of  the  former 
somewhat  different  from  that  of  the  latter.  The  salts  in  solution 
in  sea-water  act  as  powerful  stimulants  to  the  skin,  hence  sea- 
water  of  itself  is  much  less  depressing  than  ordinary  water,  so 
that  feeble  persons  who  cannot  bathe  in  the  latter  without 
suffering  great  depression  can  bathe  in  the  former  with  benefit. 
The  motion  of  the  waves,  however,  has  a  powerfully  depressing 
effect,  but  the  reaction  following  the  dashing  of  the  waves  against 
the  body  adds  greatly  to  the  invigorating  and  exhilarating  effects 
in  strong  and  healthy  persons. 

If  the  nervous  system  of  the  patient  is  so  weak  that  the  necessary 
reaction  does  not  take  place,  even  although  there  may  be  no  organic  disease, 


312  GENERAL  TREATMENT. 

outdoor  sea-bathing  must  be  prohibited,  but  an  indoor  bath,  of  sea--^ater, 

either  cold  or  with  the  chill  taken  off,  may  be  substituted.     A  considerable 

part  of  the  benefit  received  by  patients  from  residence  at  the  seaside  must 

be  ascribed  to  the  breathing  of  sea-air,  along  with  the  complete  change  of 

scene  and  occupation. 

< 

§  158.  The  Cold  Water  Pack  is  a  powerful  therapeutic  agent, 
but  it  is  seldom  employed  outside  hydropathic  establishments, 
and  there  it  is  associated  with  a  carefully  regulated  diet,  change 
of  air  and  scene,  regular  hours,  and  various  other  circumstances 
which  assist  reparative  processes,  so  that  it  is  difficult  to  deter- 
mine how  much  of  the  beneficial  effect  is  due  to  the  cold  water 
treatment.  There  can  be  no  doubt,  however,  that  the  cold 
water  pack,  along  with  the  subsequent  sponging  and  rubbing,  is 
exceedingly  refreshing,  and  under  its  use  tissue  metamorphosis 
is  accelerated,  the  nutrition  of  the  body  is  improved,  and  the 
absorption  of  effused  products  is  promoted,  hence  it  becomes  a 
valuable  remedy  in  many  organic  nervous  diseases. 

§  159.  SJioiver,  Douche,  and  Sponge  Baths  produce,  in  addition 
to  the  effects  of  the  cold  immersion,  powerful  nervous  stimulation 
from  the  impact  of  the  water  on  the  body. 

Shower  and  sponge  baths  are  useful  in  cases  of  hysteria  and  other 
functional  nervous  diseases,  while  the  douche  and  cold  affusion  are  generally 
employed  for  their  local  effects,  as,  for  example,  to  rouse  a  patient  from 
dnmkenness  or  opium  poisoning.  The  local  douche  has  also  been  found 
useful  in  the  treatment  of  paralysed  parts,  and  in  several  forms  of  sensory 
disturbance.  A  douche,  consisting  of  alternations  of  hot  and  cold  water, 
has  a  powerfully  stimulating  effect,  and  may  be  employed  in  many  cases  of 
paralysis. 

§  160.  Warm  BatJis,  by  sheltering  the  body  from  the  constant 
changes  of  the  external  air,  and  by  diminishing  oxidation,  act  as 
a  sedative  to  the  cutaneous  nerves,  and  through  them  to  the 
nervous  system  generally.  By  procuring  dilatation  of  the 
cutaneous  blood-vessels,  arterial  tension  is  lowered,  and  relief  is 
thus  afforded  to  congestion  of  internal  organs.  The  effects  vary 
considerably,  according  to  the  temperature  of  the  bath.  If  the 
temperature  be  indifferent  (90°  to  97°  F.)  the  bath  acts  mainly 
as  a  nervous  sedative,  while  warm  and  hot  baths  (97°  to  108°  F.) 


GENERAL   TREATMENT.  313 

produce  great  vascular  excitement,  and  act  as  powerful  nervous 
stimulants. 

The  geographical  position  of  the  bath  must  be  taken  into 
account,  especially  as  experience  teaches  that  the  higher  the 
elevation,  the  higher  is  the  temperature  that  can  be  borne ;  and 
that  the  more  irritable  the  patient  is,  the  more  elevated  may  be 
the  spot  to  which  he  is  sent  for  cure  (Erb).  If  the  symptoms 
of  irritation  preponderate  we  choose  the  soothing  bath,  and  if 
the  symptoms  of  depression  are  prominent,  the  exciting  bath  at 
a  higher  temperature  may  be  employed.  A  complete  list  of  hot 
springs,  and  much  useful  information  with  respect  to  spas  and 
mineral  waters  generally,  are  given  in  Squire's  Companion  to 
the  British  Pharmacopoeia,  and  the  information  given  in  a  work 
which  is  Id  the  hands  of  almost  every  practitioner  need  not  be 
repeated  here. 

§  161.  Weah  Brine  Baths,  containing  not  more  than  one  per 
cent  of  chlorides,  most  sulphur  baths,  and  the  weak  alkaline 
springs  act  like  indifferent  springs,  and  may  be  employed  in  the 
treatment  of  the  same  class  of  diseases.  These  baths  are  useful 
in  spinal  irritation  and  exhaustion  from  excess  of  any  kind,  and 
in  spinal  meningitis;  the  chronic  scleroses  of  the  spinal  cord 
require  great  care  in  the  use  of  the  warm  bath,  inasmuch  as 
cases  of  locomotor  ataxy  and  chronic  myelitis  are  often  made 
worse  by  too  warm  baths. 

§  162.  Vapour  Baths,  Hot  Sand  BatJis,  Hot  Air  Baths  pro- 
duce diaphoresis,  and  are  powerful  nervous  stimulants,  and  may 
be  used  in  the  treatment  of  the  same  class  of  cases  as  the  hot 
spring  baths. 

§  163.  Brine  Baths  differ  only  from  warm  baths  from  the  fact 
that  the  contained  salt  acts  as  a  powerful  stimulus  of  the  nutri- 
tion and  circulation  of  the  skin  ;  on  account  of  the  exciting 
effect  of  the  salt  the  temperature  may  be  somewhat  lower  than 
that  of  warm  baths.  The  most  suitable  proportion  of  salt  is  from 
two  to  four  per  cent  (Erb). 

8  164.  Warm  Brine  and  Gaseous  Baths  are  more  stimulating 


314  GENERAL   TREATMENT. 

than  the  simple  brine  baths,  inasmuch  as  the  carbonic  acid  con- 
tained in  them  powerfully  excites  the  skin  and  nervous  system. 
These  baths  should  not  exceed  90°  F.,  and  they  are  usually 
taken  without  moving  the  water,  but  when  a  strong  stimulant 
is  desirable  the  water  may  be  agitated.  They  are  indicated  in 
the  chronic  stage  of  atrophic  paralysis,  in  locomotor  ataxy,  and 
other  chronic  affections  of  the  spinal  cord,  as  well  as  in  cases  of 
functional  debility  of  the  nervous  centres. 

§  165,  Chalybeate  and  Gaseous  Baths  appear  to  act  precisely 
in  the  same  manner  as  the  alkaline  and  gaseous  baths.  The 
iron  does  not  appear  to  be  of  any  value  except  when  used 
internally. 

§  166.  Mud  BatJis  act  partly  as  warm  water  baths,  but  they 
are  much  less  exciting  than  warm  water  spring  baths,  and  are 
consequently  adapted  for  the  treatment  of  spinal  irritation  and 
paralysis  accompanied  by  excess  of  muscular  tension,  as  occurs 
in  lateral  sclerosis,  compression  of  the  cord,  and  hemiplegia  with 
descending  sclerosis.  Good  mud  baths  are  found  in  Franzensbad, 
Marienbad,  Teplitz,  Driburg,  Eilsen,  Meinberg,  Nenndorf, 
Pyrmont,  and  other  places. 

§  167.  The  Turkish  Bath  combines  many  of  the  properties  of 
the  hot  and  cold  bath.  It  produces  profuse  diaphoresis,  and 
thus  cleanses  the  system  by  carrying  off  effete  and  noxious  sub- 
stances, so  that  its  use  is  indicated  in  many  nervous  affections 
which  occur  in  rheumatic  and  gouty  constitutions.  The  great 
heat  to  which  the  body  is  subjected  tends  no  doubt  to  induce 
debility,  but  the  subsequent  free  application  of  cold  water  ex- 
cites the  cutaneous  nerves  and  braces  the  system,  so  that  the 
tonic  effects  of  the  cold  bath  are  procured.  The  systematic 
kneading  to  which  all  the  muscles  of  the  body  are  subjected 
promotes  their  own  nutrition  and  the  nutrition  of  the  nerves 
which  supply  them,  and  thus  the  effects  of  the  bath  are  combined 
with  those  which  result  from  carefully-regulated  exercise  and 
systematic  gymnastics.  The  Turkish  bath  is,  indeed,  a  powerful 
therapeutic  agent,  and  has  a  wide  range  of  usefulness  in  the 
treatment  of  various  nervous  affections. 


GENERAL   TREATMENT.  315 

§  168.  The  Needle  Bath  consists  of  an  apparatus  so  constructed 
that  numerous  jets  of  water  forcibly  impinge  on  the  body  of  the 
patient.  Hot  water  is  first  used,  and  after  a  few  minutes  it  is 
gradually  or  somewhat  suddenly  changed  for  cold  water.  The 
alternation  of  hot  and  cold  water,  as  well  as  the  impact  of  the 
jets  against  the  body,  renders  this  bath  a  powerful  stimulant, 
and  it  is  exceedingly  useful  in  the  treatment  of  chronic  nervous 
diseases.  It  is  a  very  valuable  means  of  treatment  in  locomotor 
ataxy,  for  instance,  when  the  lightning  pains  are  not  excessive, 
and  when  the  tendinous  reflexes  are  abolished.  In  lateral 
sclerosis,  when  the  reflexes  are  increased,  this  bath,  like  all  other 
stimulating  baths,  does  much  harm. 

§  169.  Climate  "  Cures" — It  has  been  found  by  experience 
that  certain  climates  and  regions  exercise  a  favourable  influence 
on  various  nervous  diseases,  especially  those  of  functional  origin. 
Sea  air  has  a  very  invigorating  effect  on  the  system,  and  it  is 
well  adapted  for  the  cure  of  states  of  nervous  exhaustion  from 
overwork  in  those  who  are  otherwise  strong  and  healthy.  Feeble 
and  irritable  people,  however,  obtain  greater  benefit  from  resi- 
dence in  a  mountainous  district.  Mountain  exercise  has  a  very 
enlivening  effect  upon  the  nervous  system,  and  the  higher  and 
drier  the  district  the  more  marked  are  the  tonic  effects.  The 
Engadine  and  Davos  Platz  are  very  favourite  mountain  resi- 
dences, and  the  Scottish  mountains,  the  English  lake  district, 
and  Ilkley  in  Yorkshire,  are  also  beneficial,  although  they  have 
neither  the  eleva.tion  nor  the  dry  atmosphere  of  the  Swiss 
mountains. 

§  170.  Blood-Letting  and  Counter-IrHtation  are  as  useful  in 
the  treatment  of  inflammatory  affections  of  the  nervous  system 
as  in  those  of  other  organs,  but  as  they  present  nothing  special 
in  their  action  or  mode  of  application  when  employed  in  the 
treatment  of  nervous  diseases,  they  do  not  require  further  con- 
sideration at  present.  The  counter-irritants  usually  employed 
are  cutaneous  faradisation,  sinapisms,  vesicants,  issues,  moxse, 
and  the  actual  cautery. 

§  171.  Seclusion. — There  is  a  growing  conviction  amongst 


/■ 


316  GENERAL  TREATMENT. 

medical  men,  who  have  much  experience  in  the  management  of 
cases  of  hysteria  and  other  forms  of  functional  nervous  diseases, 
that  such  patients  cannot,  as  a  rule,  be  satisfactorily  treated  at 
their  own  homes.  The  great  value  of  complete  isolation  of  the 
patient  from  injudicious  friends  has  been  long  acknowledged  in 
the  treatment  of  the  graver  psychoses,  but  it  is  only  in  recent 
years  that  the  value  of  this  method  in  the  treatment  of  neur- 
asthenia and  various  other  functional  nervous  disorders  has  been 
acknowledged.  Dr.  Weir  Mitchell,  who  was  the  first  to  insist 
upon  the  necessity  of  seclusion  in  the  treatment  of  such  cases, 
says :  "  Once  separate  the  patient  from  the  moral  and  physical 
surroundings  which  have  become  part  of  her  life  of  sickness, 
and  you  will  have  made  a  change  which  will  be  in  itself  bene- 
ficial, and  will  enormously  aid  in  the  treatment  which  is  to 
follow."^  Isolation  of  the  patient  is,  like  other  measures  which 
have  hitherto  been  described,  only  of  value  when  it  forms  part 
of  a  complete  scheme  of  treatment,  but  the  other  means  which 
must  be  selected  in  order  to  render  seclusion  beneficial  will  be 
best  described  in  the  special  part  of  this  work. 

§  172.  Rest — One  of  the  most  frequent  questions  which  the 
physician  has  to  decide  is,  whether  a  person  suffering  from  some 
nervous  disease  is  to  take  exercise  or  to  rest,  and  it  is  not  always 
an  easy  one  to  answer.  This  question  is  readily  decided  in  most 
cases  of  organic  disease ;  the  general  rule  is  that  physiological 
rest  is  enjoined  in  all  acute,  and  a  certain  amount  of  graduated 
exercise  in  chronic  affections.  In  the  severe  cases  of  neur- 
asthenia in  which  it  is  necessary  to  isolate  the  patient.  Dr.  Weir 
Mitchell  also  insists  upon  the  necessity  of  enforced  rest.  The 
patient  is  ordered  to  bed  for  from  six  weeks  to  two  months,  and 
during  the  greater  part  of  this  period  such  actions  as  sewing, 
reading,  and  writing  are  strictly  forbidden.  In  aggravated  cases 
the  patient  is  not  even  allowed  to  turn  over  in  bed  without  aid ; 
she  is  fed  by  the  nurse,  and  even  the  calls  of  nature  are  obeyed 
in  the  recumbent  posture. 

§  173.  Massage  is  a  general  term  meant  to  include  methodical 
rubbing,  stroking,  kneading,  and  clapping  the  surface  of  feeble 

-  Fat  and  Blood,  and  how  to  make  them,  by  S.  Weir  Mitchell,  M.D.    1878.   p.  36. 


GENERAL   TEEATMENT.  317 

and  paralysed  parts — a  method  which  is  often  successful  in  the 
treatment  of  organic  and  functional  paralyses.  Massage  has 
been  extensively  used  in  the  Manchester  Royal  Infirmary  by  my 
colleague  Dr.  Morgan,  and  with  very  gratifying  results.  The 
directions  for  carrying  out  the  process  as  practised  by  Dr. 
Morgan  are  briefly  the  following  : — 

1.  Pinch  the  surface  of  the  skin  from  below  upwards,  with  the 

view  of  stimulating  the  cutaneous  nerves.  Suppose  the 
lower  extremities  to  be  paralysed,  the  skin  of  the  foot  is 
first  drawn  up  into  successive  folds  and  lightly  pinched. 
The  skin  over  the  whole  of  the  leg,  and  finally  that  of  the 
thigh  is  gone  over  in  the  same  way. 

2.  Give  passive  movements  to  the  joints,  first  moving  each  of 

them  separately,  and  then  all  together. 

3.  Shampoo  the  limb  well.      This  is  done  by  lubricating  it 

with  some  bland  oil,  which  is  well  rubbed  into  the 
surface  by  the  tips  of  the  fingers  passing  from  below 
upwards,  the  spaces  between  the  muscular  groups  being 
specially  selected  for  rubbing. 

4.  Work  the  muscles  well  with  the  fingers.     Each  muscle,  or 

group  of  muscles,  is  grasped  between  the  ball  of  the 
thumb  and  the  fingers,  and  well  kneaded  and  rolled. 
During  this  process  the  limb  must  be  placed  in  a  position 
to  approximate  the  ends  of  the  muscles  operated  upon, 
and  thus  relax  them  to  the  utmost. 

5.  Slap  the  muscles  well  with  the  ulnar  border  of  the  hand. 

6.  Grasp  the  lower  portion  of  the  limb  between  the  hands, 

and  then  draw  them  slowly  and  firmly  upwards.  This 
movement  should  be  repeated  some  twelve  or  fifteen 
times.  In  this  manner  the  veins  are  emptied  and  the 
circulation  quickened. 

Massage  has  been  employed  by  Dr.  Weir  Mitchell  as  a  means  of 
increasing  the  general  nutrition  of  the  body  in  cases  of  neuras- 
thenia and  other  functional  diseases,  and  thus  counteracting  the 
evils  which  might  otherwise  result  from  seclusion  and  enforced 
rest,  but  his  complete  scheme  of  treatment  will  be  subsequently 
more  fully  described. 


818  GENERAL  TEEATMENT. 

§  174.  External  Frictions  are  usefully  employed  in  various 
nervous  affections.  Frictions  with  soothing  liniments,  warm  oil, 
opium,  and  belladonna  ointment,  and  various  other  agents,  are 
used  to  allay  pain  in  neuralgic  and  other  painful  affections. 
Frictions  with  spirituous  liniments,  either  alone  or  combined 
with  other  stimulants,  such  as  ammonia  and  camphor,  are  used 
in  the  treatment  of  various  forms  of  paralysis. 

§  175.  Swedish  Gymnastics  are  a  mere  modification  of  ordinary 
gymnastics,  the  object  being  to  aid  the  recovery  of  paralysed  or 
rather  paretic  parts,  by  bringing  the  muscles  into  methodical 
exercise.  The  patient  is  instructed  to  make  systematic  voluntary 
efforts  to  move  the  paralysed  muscles,  and  when  a  certain  degree 
of  voluntary  movement  is  attained  the  effect  is  increased  by  the 
opposition  of  a  practised  assistant.  If,  for  example,  the  flexors 
of  the  forearm  are  to  be  exercised  the  forearm  is  first  extended, 
and  the  patient  endeavours  to  flex  it  whilst  the  assistant  opposes 
flexion  with  more  or  less  force.  In  the  case  of  associated  move- 
ments it  is  often  necessary  to  aid  the  contraction  of  one  group 
of  muscles  so  as  to  overcome  the  contraction  of  their  antagonists, 
which  are  also  excited  to  action  during  the  voluntary  effort  to 
contract  the  paralysed  group.  The  assistant  must  then  aid  the 
paralysed  muscles  by  passively  extending  the  healthy  antagonist 
muscles.  The  action  of  the  healthy  antagonist  muscles  can  be 
weakened,  not  only  by  the  hands  of  an  assistant,  but  also  by 
fixing  elastic  bands  or  spiral  wires  to  the  limb  so  as  to  aid  the 
action  of  the  paralysed  groups.  Ordinary  gymnastic  exercises 
are  also  useful  in  the  treatment  of  various  nervous  affections. 
By  their  use  the  nutrition  of  the  muscular  system  is  improved, 
the  heart  propels  the  blood  more  efficiently  through  the  organism, 
the  blood  itself  becomes  of  better  quality,  and  the  nervous  system 
participates  in  the  general  improvement. 

§  176.  Mechanical  Vibrations. — Some  years  ago  Dr.  Mor- 
timer Granville^  was  led  to  try  the  effects  of  rapidly  tapping  the 
skin  over  the  fifth  nerve  in  a  case  of  facial  neuralgia  by  means 
of  a  Bennett's  percussion  hammer,  using  the  pleximeter  as  a 

'  See  Granville  (J.  Mortimer!.  "Treatment  of  pain  by  mechanical  vibrations." 
The  Lancet,  Vol.  I.,  1881,  p.  286  ;  and  Vol.  I.,  1882,  p.  919. 


GENERAL  TREATMENT.  319 

shield.  The  results  obtained  were  so  encouraging  that  he 
gradually  extended  the  application  of  mechanical  vibration  as  a 
therapeutic  remedy  to  various  other  nervous  diseases.  With  the 
view  of  better  regulating  the  number  and  strength  of  the  blows 
which  can  be  delivered  in  a  given  time,  Dr.  Granville  had  an 
instrument  constructed  which  he  names  "  percuteur."  The 
newest  and  most  efficient  percuteur  is  worked  by  electricity,  but 
it  is  important  to  remember  that  no  electricity  passes  through 
the  patient ;  the  electricity  is  converted  into  mechanical  motion, 
and  its  only  use  is  to  enable  the  performer  to  deliver  a  regulated 
number  of  blows  on  any  desired  part,  just  as  was  done  more 
roughly  by  means  of  Bennett's  percussion  hammer.  The  author 
illustrates  the  manner  in  which  he  believes  his  method  relieves 
pain  in  neuralgia  by  reference  to  Professor  Tyndall's  experiments 
on  musical  sounds.  Prof  Tyndall  showed  that  two  discordant 
musical  notes  may  be  made  to  interfere  with  one  another  in  such 
a  way  as  to  produce  silence,  and  Dr.  Granville^  thinks  that  the 
mechanical  vibrations  of  his  instrument  introduce  discord  into 
the  rhythm  of  the  morbid  vibrations,  and  thus  relieve  the  pain 
of  neuralgia.  But  whether  this  be  so  or  not,  he  finds  that  an 
acute  sharp  pain  is  best  relieved  by  a  comparatively  low  number 
of  vibrations  per  second,  while  a  dull,  massive,  or  grinding  pain 
is  more  likely  to  be  arrested  by  a  quick  movement  of  the  instru- 
ment. Dr.  Granville  speaks  of  his  method  throughout  with  the 
greatest  caution,  and  he  appears  to  be  particularly  anxious  to 
avoid  anything  like  the  sensationalism  which  so  frequently  sur- 
rounds the  introduction  of  new  modes  of  treatment.  He  thinks 
at  the  same  time  that  in  mechanical  vibrations  we  have  a  thera- 
peutic agent  of  singular  power.  By  its  means  he  believes  that 
he  can  relieve  a  considerable  number  of,  but  not  all,  cases  of 
neuralgia ;  that  much  amendment  occurs  by  its  use  in  the  early 
stages  of  locomotor  ataxia  and  lateral  sclerosis ;  and  that  by  it 
he  can  even  arouse  torpid  nerve  centres  to  action,  and  conse- 
quently that  it  is  of  great  use  in  the  treatment  of  neurasthenia. 

§  177.  Electricity  in  its  various  forms  is  not  only  one  of  the 
most  useful  remedies  we  possess  for  the  treatment  of  disease  of 

1  Granville  (J.  Mortimer).     "Nerve  Vibration  as  a  therapeutic  agent."     The 
Lancet,  Vol.  I.,  1882,  p.  749. 


320  GENEKAL  TREATMENT. 

the  nervous  system,  but  it  is  also  a  remedy  which  is  almost 
exclusively  adapted  for  the  treatment  of  nervous  disease.  The 
therapeutical  applications  of  this  agent,  therefore,  demand 
from  us  a  somewhat  lengthened  examination.  The  varieties  of 
electricity  are — (i.)  Franklinism ;  (ii.)  Faradism;  and  (in.) 
Galvanism.  The  act  of  applying  electricity  in  the  treatment 
of  disease  is  called  Electrisation,  while  the  acts  of  applying  its 
varieties  are  respectively  called  FranJdinisation,  Faradisation, 
and  Galvanisation.  For  a  description  of  the  various  instru- 
ments used  in  applying  electricity  we  must  refer  the  reader  to 
systematic  works  on  electro-therapeutics,  and  to  all  respectable 
surgical  instrument  makers,  who  now  keep  in  stock  reliable 
medical  electrical  machines  with  their  accessories. 

(i.)  Franklinism,  Friction,  or  Static  Electricity,  is  generated 
in  the  usual  way  by  a  plate  machine, 

§  178.  Methods  of  Application. 

(1)  Electro-Positive  Bath. — The  patient  must  be  insulated  by  being 
placed  on  a  glass-legged  stool  or  couch,  and  then  connected  by  a  brass  chain, 
held  in  his  hand,  with  the  prime  conductor  of  the  machine.  When  the 
plate  of  the  machine  is  rotated  both  the  conductor  and  the  patient  become 
charged  with  positive  electricity,  hence  the  patient  is  said  to  be  taking  an 
electro-positive  hath. 

In  order  to  prevent  the  moisture  of  the  atmosphere  from  carrying  off 
the  charge,  the  plate,  the  insulating  supports,  the  legs  of  the  stool,  and  all 
the  glass  part  of  the  apparatus  should  be  well  rubbed  with  a  warm  and  dry 
piece  of  flannel. 

(2)  Electro -Negative  Bath.— If  the  chain  held  in  the  hand  of  the  j)atient 
be  connected  with  the  cushions  of  the  machine,  instead  of  with  the  con- 
ductor, he  becomes  charged  with  negative  electricity,  and  is  said  to  be  taking 
an  electro-negative  bath. 

(3)  Franldinisation  by  Sparks. — If,  when  the  patient  is  in  connection 
with  the  prime  conductor,  any  object  be  brought  near  to  him,  he  is  dis- 
charged with  a  spark  ;  the  discharge  is  accompanied  by  a  slight  shock,  and 
is  called  Franklinisation  by  sparks.  The  electricity  may  be  localised  to 
some  extent  without  producing  a  shock  by  passing  a  metallic  brush  slowly 
along  the  course  of  a  nerve  trunk  or  a  muscle,  almost  but  not  quite  in 
contact  with  the  skin. 

(4)  Franklinisation  by  the  Ley  den  Jar. — A  Leyden  jar  is  charged  in  the 
usual  way,  and  is  discharged  by  applying  the  extremities  of  the  exciters  to 
two  points  of  the  body  through  which  it  is  desired  the  electricity  should 
pass.     Franklinisation  is  not  a  method  of  treatment  of  which  I  have  per- 


GENERAL   TREATMENT.  821 

sonally  mucb.  experience ;  but  Dr.  Tibbits  sj)eaks  favourably  of  it  as  a 
remedy  in  neuralgia,  sparks  being  drawn  along  the  track  of  the  affected 
nerves  ;  also  in  facial  spasm,  emotional  aphonia,  hysterical  hyperaesthesia, 
and  various  forms  of  tremor. 

(ii.)  Farcodism. — The  induced  or  interrupted  current,  as  it  is 
variously  called,  was  discovered  by  Faraday,  and  is  generated  or 
induced  in  a  coil  of  copper  wire  by  the  action  of  a  permanent 
magnet,  or  of  a  voltaic  current.  The  instruments  constructed  to 
generate  the  faradic  current  possess  two  coils,  called  the  primary 
and  secondary  coil,  from  each  of  which  a  current  is  obtained  ; 
these  are  respectively  called  the  primary  induced  and  the 
secondary  induced  current.  The  current  induced  in  the  secondary 
possesses  greater  tension  than  that  of  the  primary  coil ;  hence 
the  former  penetrates  more  readily  through  the  tissues  than  the 
latter,  and  consequently  acts  as  a  more  efficient  stimulus  to  the 
nerves  and  muscles, 

§179.  Methods  of  Application. 

(1)  General  Faradisation. — This  method  of  employing  the  faradic  current 
was  first  introduced  by  Drs.  Beard  and  Eockwell,  with  the  view  of  bringing 
"  every  portion  of  the  body  under  the  influence  of  the  faradic  current,  so 
far  as  is  possible  by  external  applications."^  In  accomplishing  this  object 
one  pole,  usually  the  negative,  is  placed  at  the  foot  or  coccyx,  while  the 
other  is  applied  over  the  surface  of  the  body,  and  is  either  kept  stationary 
at  certain  points  or  moved  over  the  surface,  while  the  current  may  be 
maintained  imiform  or  increasing. 

For  the  negative  electrode  a  piece  of  copper  plate  is  used,  which  must 
be  slightly  warmed  in  cold  weather,  and  kept  moistened  by  warm  water  in 
order  to  improve  the  conduction.  A  brass  ball,  one  inch  in  diameter, 
aroimd  which  is  loosely  folded  a  wet  sponge  of  about  six  inches  in 
diameter,  is  recommended  for  the  positive  electrode.  The  patient  is 
usually  seated  on  an  ordinary  stool  with  his  face  towards  the  instnunent, 
and  his  naked  feet  placed  upon  the  copper  plate  to  which  the  negative  pole 
is  attached. 

It  is  not  necessary  to  apply  the  positive  pole  to  all  parts  of  the  surface. 
The  locahties  selected  for  special  attention  are  the  spine,  especially  the 
ciHo-spinal  region,  the  anterior  border  of  the  sterno-mastoids  over  the 
carotids  to  reach  the  pneumogastrics  and  cervical  sympathetics,  the  pos- 
terior triangles  of  the  neck  to  reach  the  brachial  plexuses,  the  epigastrimn 
to  reach  the  solar  plexus,  and  the  surfaces  overlying  the  large  nerve  trunks 

^  A  practical  treatise  on  the  Medical  and  Surgical  Uses  of  Electricity,  by  G.  M. 
Beard  and  A.  D.  Rockwell.    Third  edit.,  1881,  p.  347. 

VOL.  I.  V 


322  GENERAL  TREATMENT. 

in  tlie  lower  extremities.  Applications  are  made  to  tlie  head  through  the 
forehead,  vortex,  and  occiput.  It  must  be  remembered  that  the  forehead 
is  very  sensitive  to  the  current,  while  the  back  of  the  head  will  bear  com- 
paratively strong  currents.  In  making  applications  to  the  forehead  and 
to  those  parts  of  the  body  generally  in  which  the  bones  come  near  to  the 
surface,  the  "  electric  hand  "  to  be  immediately  described  may  be  employed 
for  the  positive  pole  instead  of  the  sponge  electrode.  The  dm-ation  of  each 
sitting  may  range  between  five  and  twenty-five  minutes.  An  average 
sitting  of  fifteen  minutes  may  be  given  to  the  head,  four  to  the  neck  and 
cervical  spine,  three  to  the  back,  three  to  the  abdomen,  and  four  to  the , 
upper  and  lower  extremities. 

(2)  Localised  Faradisation  is,  as  its  name  imphes,  the  apphcation  of 
the  faradic  current  to  special  organs  or  tissues.  This  mode  of  application 
admits  of  the  following  subdivision : — (a)  Cutaneous  faradisation ;  (6)  Neuro- 
muscular faradisation  ;  and  (c)  Faradisation  of  internal  organs  and  of  the 
special  senses. 

(a)  Cutaneous  Faradisation. — ^When  it  is  desired  to  limit  the  current  to 
the  cutaneous  sm-face  the  rheophores  must  be  used  dry,  and  the  skin  should 
also  be  dusted  with  some  absorbent  powder,  so  as  to  diminish  its  conduc- 
tion. Besides  the  usual  rheophores  other  methods  are  adopted  for  applying 
cutaneous  faradisation. 

(i.)  The  Electric  Hand. — A  moist  rheophore  is  applied  to  some  sUghtly 
sensitive  part  of  the  patient's  body,  as  over  the  sternum  ;  the  other  rheo- 
phore is  held  in  the  hand  of  the  operator,  who  passes  the  back  of  the 
disengaged  hand  over  the  surface  which  it  is  desired  to  excite. 

(ii.)  Solid  Metallic  Rheophores  are  appHed  by  thin  metallic  siu-faces  to 
the  dry  skin,  and  are  either  kept  stationary  or  stroked  over  the  surface. 
If  the  rheophore  is  conical,  and  maintained  for  some  time  immovable,  it 
produces  a  sensation  similar  to  that  caused  by  a  hot  nail  penetrating  the 
skin  ;  hence  it  is  termed  the  electric  nail. 

(iii.)  Metallic  Threads. — A  wire  brush  may  be  substituted  for  one  of  the 
ordinary  rheophores  and  moved  over  the  skin,  constituting  electric  cauterisa- 
tion ;  used  to  strike  it  hghtly,  constituting  what  is  called  electric  fustigation  ; 
or  held  in  contact  with  it,  forming  an  electric  moxa. 

{b)  Neuro- Muscular  Faradisation. — When  it  is  desired  to  reach  the 
deeper  tissues  through  the  skin,  it  must  be  remembered  that  the  latter  is  a 
bad  conductor  of  electricity,  and,  consequently,  the  rheophores  should 
consist  of  well  moistened  sponges  contained  in  cyhnders,  or  metaUic  discs, 
covered  with  wet  leather;  and,  in  addition,  the  skin  itself  should  be 
thoroughly  moistened  with  a  mixture  of  warm  water  and  common  salt, 
which  increases  its  electric  conductivity.  When  the  muscles  are  excited  to 
contraction  through  the  skin,  the  method  is  called  the  percutaneous  appli- 
cation. The  current  may,  however,  be  passed  directly  into  the  muscle  which 
it  is  desired  to  contract,  by  passing  needles  into  its  substance ;  and  this 
method  is  called  electro-puncture  or  electric  acupunct^ire.     Electro-puncture 


GENERAL  TREATMENT.  823 

was  introduced  into  practice  upwards  of  fifty  years  ago  by  Sarlandifere,^  who 
thrust  insulated  needles  through  the  skin  into  the  muscles ;  but  the  powerful 
opposition  of  Duchenne,  along  with  the  brilliant  results  he  himself  obtained 
by  the  percutaneous  application  of  the  current,  combined  to  render  the 
practice  of  electro-puncture  almost  entirely  obsolete.  A  few  years  ago, 
Dr.  Morgan^  introduced  the  practice  of  electric  acupuncture  into  the  Royal 
Infirmary,  Manchester,  being  at  the  time  unconscious  that  it  was  a  revival 
of  an  old  practice,  and  no  one  can  have  watched,  from  day  to  day,  the 
satisfactory  results  obtained  by  him  without  being  convinced  that  this 
method  often  oflfers  numerous  advantages  over  percutaneous  application. 
Dr.  Morgan  at  first  used  insulated  needles,  but  he  soon  discarded  them  for 
needles  which  are  not  insulated.  "  The  needles  I  now  use,"  he  says,  "  are 
as  fine  as  can  be  manufactured;  they  vary  in  length  from  two  to  four 
inches,  and  have  a  metallic  knot,  the  size  of  a  small  pea,  attached  to  one 
end."  Several  of  these  needles  are  thrust  into  the  muscle  which  it  is 
desired  to  excite  to  contraction,  and  while  one  rheophore  (generally  the 
anode),  with  moistened  sponge,  is  placed  on  an  indifferent  part  of  the  body, 
the  knobs  of  the  needles  are  successively  touched  with  the  metallic  part  of 
the  other  rheophore,  and  an  instantaneous  upward  or  downward  movement 
of  the  needle  indicates  when  contraction  occm's.  The  muscles  may  be 
excited  to  contract  by  passing  the  faradic  current  through  their  substance, 
either  percutaneously  or  by  electro-puncture,  or  by  placing  the  exciting 
rheophore  over  the  nerve  trunk  or  branch  which  supplies  the  muscle.  The 
former  method  of  application  is  called  direct  muscular  faradisation,  and  the 
latter  indirect  muscular  faradisation. 

(i.)  Direct  Muscular  Faradisation. — For  the  direct  electrisation  of 
muscles,  which  present  a  large  surface,  like  those  of  the  trunk,  it  is  most 
convenient  to  use  moistened  sponges,  contained  in  cylinders ;  but  when  the 
muscles  are  small,  as  those  of  the  face  and  the  interossei,  metallic  rheophores, 
with  rounded  or  conical  points  and  covered  with  wet  wash-leather,  should 
be  employed.  In  order  to  electrise  a  muscle  completely,  the  rheophores 
should  be  applied  over  its  fleshy  body,  and  they  should  either  cover  its 
whole  surface  or  be  applied  in  succession  to  all  points  of  its  surface.  When 
the  body  of  the  muscle  is  very  thick,  a  strong  current  must  be  employed, 
otherwise  the  superficial  layers  alone  are  excited.  The  points  to  which  the 
rheophores  must  be  applied,  in  order  to  stimulate  directly  any  particular 
muscle,  can  only  be  known  from  a  fuU  acquaintance  of  the  anatomy  of  the 
muscular  system.  Sufficient  information  for  the  practical  use  of  direct 
electrisation  will  be  found  in  the  special  part  of  this  work ;  and  for  any 
further  information  we  must  refer  the  reader  to  ordinary  anatomical  works. 

(ii.)  Indirect  Muscular  Faradisation. — In  order  to  obtain  contraction 
of  a  muscle,  or  a  group  of  muscles,  by  passing  a  current  through  the  nerve 
which  supplies  it,  a  broad  conductor,  or  a  wet  sponge  contained  in  a  cylinder, 

1  See  Duchenne.    L'electrisation  localia^e,  1855,  p.  83. 
'^  The  Lancet,  Vol.  II.,  1879,  pp.  454  and  499. 


324  GENERAL  TREATMENT. 

should  be  placed  upon  an  indifferent  part  of  the  body,  as  the  sternum,  while 
a  fine  pointed  conductor,  such  as  a  conical  rheophore,  is  applied  over  the 
most  superficial  part  of  the  nerve  it  is  desired  to  excite.  To  ensure  success 
a  minute  knowledge  of  the  anatomy  of  the  muscles  and  nerves,  and  of  their 
relations  to  the  surface  of  the  body,  is  essential.  It  must  be  remembered, 
however,  that  the  course  and  distribution  of  the  nerves  are  hable  to  con- 
siderable variations,  so  that  the  points  suitable  for  excitation — or  the  motor 
points,  as  they  are  called — can  only  be  pointed  out  approximately.  It  is, 
therefore,  necessary  in  practice  to  make  a  few  trials  before  the  true  motor 
point  for  a  particidar  group  of  muscles  is  ascertained.  The  motor  points 
for  each  nerve,  trunk,  and  muscular  branch  have  been  carefully  determined 
by  Ziemssen,  and  his  figures,  copied  by  permission  from  Dr.  Tibbits'  book, 
will  be  found  in  the  special  part  of  the  work.  By  the  aid  of  these  figures 
the  student  can  approximately  determine  the  motor  points  for  each  nerve 
and  muscle  accessible  to  electrisation. 

(c)  Faradisation  of  Internal  Organs  and  Special  Senses. — The  faradic 
current  may  be  appHed  directly,  by  means  of  suitable  conductors,  to  a  great 
many  of  the  internal  organs,  such  as  the  rectum,  bladder,  uterus,  male 
genital  organs,  larynx,  CBSophagus,  and  stomach ;  but  for  further  information 
upon  this  subject  we  must  refer  the  reader  to  special  works  on  electric 
therapeutics.  The  faradic  current  is  but  rarely  employed  in  the  treatment 
of  the  affections  of  special  sense,  its  use  being  superseded  by  that  of  the 
galvanic  current. 

(ill.)  Galvanism. — The  Galvanic,  Voltaic,  Dynamic,  or 
Constant  Current,  as  it  is  variously  called,  is  the  electricity  of 
chemical  action  discovered  by  Volta  and  Galvani.  The  current 
of  electricity  passes  from  the  positive  pole  or  anode  to  the  nega- 
tive pole  or  cathode,  and  for  medical  purposes  it  should  be  both 
continuous  and  constant,  inasmuch  as  any  interruptions  or  con- 
siderable variations  in  the  power  of  the  current  would  alter  its 
character,  and  render  its  applications  for  several  purposes  both 
untrustworthy  and  daagerous.  The  intensity  of  the  current 
depends  on  the  number  of  cells  employed,  and  its  quantity  on 
the  size  of  the  elements.  The  currents  used  in  medicine  are 
of  low  tension  and  considerable  quantity. 

§  180.  Methods  of  Application. 

All  that  has  already  been  said  with  respect  to  percutaneous  faradisation 
and  faradisation  by  acupuncture,  as  well  as  to  direct  and  indirect  muscidar 
faradisation,  applies  equally  to  the  application  of  the  galvanic  current.  It 
is  unnecessary,  therefore,  to  repeat  what  has  been  said  with  regard  to  the 
necessity  of  having  both  the  rheophores  and  skin  well  moistened  with  warm 


GENERAL   TREATMENT.  825 

water  and  salt  when  the  current  is  apphed  percutaneously,  or  to  the  choice 
of  the  motor  points  both  in  direct  and  indirect  musciilar  galvanisation. 
Owing  to  the  low  tension  of  the  galvanic  current  its  application  by  acupunc- 
tvu-e  is  of  even  more  importance  and  value  than  a  similar  application  of  the 
faradic  current,  the  latter,  from  its  higher  tension,  being  able  to  penetrate 
deeper  through  the  tissues. 

(1)  Stabile  Application. — According  to  this  method  the  rheophores  are 
maintained  immovable  on  the  skin,  or  the  affected  extremities  are  placed 
in  tepid  salt  water,  with  which  the  conducting  wires  of  the  battery  are  in 
contact. 

(2)  Labile  Application. — In  this  method  the  cathode  is  made  to  glide 
over  the  skin,  in  the  direction  of  the  nerves  and  muscles  to  be  acted  on. 

(3)  Interrupted  Currents  and  Voltaic  Alternatives. — The  constant  current 
acts  as  a  stimulus  to  both  nerves  and  muscles  at  the  moment  of  making 
and  breaking  contact ;  hence  if  it  is  desired  to  produce  muscular  contraction 
the  current  is  internipted  by  suddenly  removing  one  of  the  rheophores,  and 
reformed  by  the  rheophore  being  suddenly  applied  again.  When  by  the  aid 
of  a  commutator  the  current  is  not  only  interrupted,  but  also  suddenly 
passed  in  the  opposite  direction — a  descending  current,  for  instance,  being 
suddenly  changed  for  an  ascending  current — the  method  has  been  called  by 
Remak,  who  introduced  the  practice,  voltaic  alternatives.  Sudden  reversal 
is  a  much  more  powerful  stimulant  both  to  nerve  and  muscle  than  simple 
interruption  of  the  current. 

(4)  Tlie  Direction  and  Polar  Methods. — In  the  direction  method  one 
rheophore  is  placed  over  the  plexus,  and  the  other  over  the  trunk  of  the 
nerve.  When  the  anode  is  centrally  placed  the  current  is  called  a  descending 
current  J  and  when  the  cathode  occupies  that  position  the  ciu-rent  is  called 
an  ascending  current.  In  the  polar  method  one  rheophore  is  placed  on  an 
indifferent  part  of  the  body,  such  as  the  sternum,  and  the  other  is  placed 
over  the  nerve  which  it  is  desired  to  stimulate.  It  was  at  one  time  sup- 
posed that  these  two  methods  of  application  involved  two  different  principles 
of  action,  but  the  effects  produced  can  be  resolved  into  the  same  principles 
in  both  cases.  When  the  cathode  is  used  as  the  exciting  pole  in  the  polar 
method  the  same  kind  and  degree  of  contraction  is  obtained  as  when  the 
cathode  is  peripherally  placed  in  the  direction  method  ;  and,  conversely, 
when  the  anode  is  used  as  the  exciting  pole  in  the  polar  method  the 
reactions  obtained  are  the  same  as  those  produced  when  the  anode  is  peri- 
pherally placed  in  the  direction  method. 

(5)  General  Galvanisation  : — 

(a)  Centralised  Galvanisation. — Under  this  name  Drs.  Beard  and  Rockwell^ 
have  recommended  a  method  of  applying  the  galvanic  cm-rent  with  the  view 
of  bringing  the  brain,  spinal  cord,  sympathetic  system,  and  the  pneumogastric 
nerves  under  its  influence.     The  cathode  is  placed  over  the  epigastrium  ; 

*  Beard  and  Rockwell.     Op.  cit,  p.  376. 


326  GENEEAL   TREATMENT. 

wMle  the  anode  is  passed  over  the  forehead  and  top  of  the  head,  along  the 
inner  border  of  the  stemo-mastoid  miiscle,  from  the  mastoid  fossa  to  the 
sternum,  and  at  the  nape  of  the  neck  and  down  the  entire  length  of  the  spine. 
The  great  aim  in  centralised  galvanisation  is  to  influence  the  central  nervous 
system,  while  the  aim  of  general  faradisation  is  to  influence  the  muscular 
system. 

(6)  Electric  Bath. — There  are  several  forms  of  electric  bath,  but  the 
simplest  is  that  in  which  one  pole  of  the  battery  is  connected  with  the 
water  in  which  the  body  is  immersed  ;  while  the  patient  grasps  in  his 
hands  a  copper  bar  covered  with  wet  flannel,  and  in  connection  with  the 
second  pole  of  the  battery. 

(6)  Localised  Galvanisation. — The  methods  of  local  application  of  the 
galvanic  current  admit  of  the  same  subdivisions  as  those  of  the  faradic 
current,  namely  (a)  cutaneous  galvanisation,  (6)  neuro-muscular  galvani- 
sation, and  (c)  galvanisation  of  the  special  senses  and  internal  organs. 

(a)  Cutaneous  Galvanisation. — In  applying  the  galvanic  current  to  the 
skin  the  same  precautions  must  be  adopted  with  respect  to  the  use  of  dry 
rheophores  as  were  mentioned  in  the  case  of  the  faradic  current.  The  local 
application  of  the  galvanic  current  to  the  skin  has  been  found  useful  in  the 
treatment  of  some  skin  diseases,  as  eczema  and  herpes.  Its  use  in  removing 
small  nsevi,  and,  indeed,  its  surgical  uses  generally,  as  well  as  the  appUca- 
tions  of  electrolysis  for  the  cure  of  aneurism,  will  be  passed  over  here 
entirely  as  not  being  part  of  our  subject.  In  the  treatment  of  peripheral 
neuralgia  one  or  both  poles  are  placed  over  the  track  of  the  cutaneous 
sensory  nerve,  and  it  is  particularly  advantageous  to  place  one  of  the  poles 
in  succession  over  the  points  douloureux.  Directions  for  the  selection  of 
these  tender  spots  will  be  given  in  the  special  part  of  the  work. 

(6)  Neuro-muscular  Galvanisation. — The  law  of  muscular  contraction,  as 
well  as  the  applications  of  electricity  in  aiding  the  diagnosis  of  the  various 
forms  of  paralysis,  has  already  been  described,  and  need  not  be  repeated 
here.  Direct  galvanisation  is  foimd  very  useful  in  the  treatment  of  paralysed 
muscles  which  manifest  the  reaction  of  degeneration.  In  such  cases  anodal 
opening  forms  the  most  powerful  stimulus  to  the  muscles,  and  the  cathode 
may  be  placed  on  some  indifferent  point  of  the  body.  When  the  catalytic 
action  of  the  ciu-rent  is  desired  a  stabile  or  labile  appHcation  of  the  cmrent 
should  be  employed,  and  it  does  not  appear  to  affect  the  result  obtained 
whether  the  ascending  or  descending  current  be  employed. 

(c)  Galvanisation  of  the  Special  Senses  and  Internal  Organs. — In  gal- 
vanisation of  the  organs  of  special  sense  one  moistened  rheophore  is  placed 
upon  the  face  and  the  second  on  the  organ  requiring  treatment.  In  gal- 
vanisation of  the  retina  the  second  moistened  rheophore  is  placed  over  the 
closed  eye.  The  retina  is  peculiarly  sensitive  to  the  galvanic  current,  and 
flashes  of  light  are  observed  from  its  stimulation  when  the  current  is 
passed  through  any  part  of  the  head  and  face.  In  galvanisation  of  the 
auditory  nerve  the  external  meatus  is  partly  filled  with  tepid  water,  and 
a  metaUic  rheophore,  insulated  by  ivory  or  vulcanite  except  at  the  ex- 


GENEEAL  TREATMENT.  327 

tremity,  is  placed  in  it  so  as  to  dip  into  the  water.  Galvanisation  of  the 
olfactory  nerve  is  effected  by  moving  a  metaUic  sound,  insulated  except  at 
its  extremity,  over  all  the  points  of  the  nasal  mucous  membrane.  In 
applying  the  current  to  the  tongue  the  rheophore  is  moved  over  the  base 
and  borders  of  the  tongue,  while  the  second  is  placed  over  the  back  of 
the  neck. 

(d)  Galvanisation  of  the  Brain  may  be  effected  by  placing  an  electrode 
on  each  mastoid  process,  or  each  temple,  or  the  frontal  and  occipital  pro- 
tuberances. The  sitting  should  not  exceed  thirty  seconds,  and  the  current 
should  be  instantly  stopped  on  the  occurrence  of  the  least  giddiness. 

(e)  Galvanisation  of  the  Sympathetic. — Benedikt  advises  galvanisation 
of  the  cervical  ganglia  of  the  sympathetic  for  the  rehef  of  symptoms  of 
intercranial  origin.  One  electrode  may  be  deeply  pressed  into  the  auriculo- 
maxUlary  fossae,  and  the  other  with  a  good-sized  sponge  apphed  over  the 
sixth  or  seventh  cervical  vertebra,  or  to  the  manubrium  sterni,  close  to  the 
border  of  the  sterno-mastoid.  The  duration  should  be  from  one  to  three 
or  four  minutes,  and  with  ten  to  twenty  cells. 

(/)  Galvanisation  of  the  Spinal  Cord. — Either  the  stabile  or  labile 
application  of  the  current  may  be  employed  in  the  treatment  of  the  spinal 
cord.  In  the  former  method  either  pole  may  be  placed  on  the  nape  of  the 
neck,  while  the  other  is  placed  over  the  liunbar  region  or  on  a  nerve  or 
muscle.  When  only  a  small  portion  of  the  spinal  cord  requires  treatment 
the  poles  must  be  placed  so  as  to  include  the  diseased  portion  in  the  circuit. 
In  the  labile  application  the  anode  is  placed  on  the  nape  of  the  neck  or 
above  the  limit  of  the  lesion,  and  the  cathode  is  moved  up  and  down  by  the 
sides  of  the  vertebr89,  about  forty  times  at  each  sitting.  As  the  current 
must  penetrate  deeply  before  reaching  the  spinal  cord  a  strong  current  must 
be  used,  and  large  moist  electrodes,  presenting  not  less  than  four  square 
inches  of  surface,  should  be  employed  so  as  to  diminish  the  pain  on  the 
surface.  Galvanisation  of  the  internal  organs  may  be  applied  by  methods 
similar  to  those  adopted  for  the  application  of  the  faradic  current. 

§  181.  Uses  of  Electricity. — The  uses  of  electricity,  in  the 
treatment  of  various  nervous  diseases,  will  be  described  in  the 
special  part  of  this  work ;  but  it  will  be  useful  to  mention  here 
one  or  two  general  principles  which  underlie  all  the  medical 
applications  of  this  physical  agent.  The  faradic  current  is  a 
powerful  stimulant  to  both  nerves  and  muscles,  and  when  a 
simple  stimulant  efifect  is  alone  desired,  this  current  is,  as  a  rule, 
more  applicable  than  the  galvanic  current.  The  faradic  current 
is,  therefore,  a  valuable  agent  in  the  treatment  of  all  diseases  of 
the  nervous  system  in  which  the  irritability  is  depressed,  no 
matter  whether  this  declare  itself  by  sensory  or  motor  paralysis. 
It  may,  therefore,  be  used  as  a  cutaneous  stimulant,  either  to  act 


328  GENERAL  TREATMENT. 

on  the  skin  directly  in  cases  of  anaesthesia,  or  to  act  on  remote 
organs  in  a  reflex  manner ;  or  it  may  be  used  as  a  powerful 
neuro-muscular  stimulant  in  the  various  forms  of  paralysis. 

The  Galvanic  Current  acts  as  a  stimulant  to  nerves  and 
muscles  both  on  making  and  breaking  contact,  and  in  addition 
produces  a  profound  alteration  of  nutrition  during  the  time  the 
current  is  interruptedly  passing  through  an  organ.  The  latter 
action  has  been  called  by  Remak  its  catalytic  action,  and  it  is 
to  it  probably  that  the  constant  current  owes  the  many  advan- 
tages it  possesses  over  the  faradic  current  in  the  treatment  of 
many  of  the  diseases  of  the  nervous  system.  The  stimulant 
action  of  the  constant  current  is,  however,  very  important  both 
as  a  means  of  diagnosis  and  in  the  treatment  of  paralysis.  We 
have  seen  that  while  paralysed  muscles  manifest  the  reaction 
of  degeneration,  they  are  more  sensitive  to  the  action  of  the 
galvanic  than  of  the  faradic  current,  and  in  these  cases  the 
constant  current  should  be  selected  to  stimulate  the  nutrition  of 
the  affected  muscles.  With  this  exception,  however,  the  faradic 
is  a  more  powerful  agent  in  the  direct  treatment  of  paralysed 
muscles  than  the  constant  current.  But  the  catal3''tic  action  of 
the  constant  current  renders  it  an  exceedingly  valuable  agent  in 
modifying  the  nutrition  of  the  nerves  and  trunks  of  the  central 
organs  of  the  nervous  system,  and  it  may  even  be  used  in  the 
treatment  of  cases  where  the  irritability  of  portions  of  the  nervous 
system  is  increased,  and  to  which,  therefore,  the  faradic  current 
is  wholly  inapplicable.  As  examples  of  the  numerous  applications 
of  the  constant  current,  may  be  mentioned  its  employment  for 
the  relief  of  pain  in  neuralgia,  and  the  assuaging  of  various  forms 
of  spasm,  not  to  speak  of  its  numerous  applications  both  locally 
and  generally  in  the  treatment  of  chronic  diseases  of  the  brain, 
spinal  cord,  special  senses,  and  viscera. 

§  182.  (4)  To  Allay  or  Remove  Serious  Symptoms. 

The  fourth  indication  of  treatment  is  to  allay  or  remove 
serious  symptoms,  and  of  these  the  distressing  symptom  of  pain 
is  by  far  the  most  prominent  and  important.  Of  all  the  internal 
remedies  which  can  be  used  for  alleviating  pain,  opium  and  its 
various  preparations  are  by  far  the  most  important.  This  drug, 
however,  appears  to  increase  the  irritability  of  the  spinal  cord, 


GENEKAL   TREATMENT.  329 

and  it  must  be  administered  with  caution  where  pain  is  asso- 
ciated with  reflex  spasm.  Bromide  of  potassium,  chloride  of 
ammonia,  chloral,  croton  chloral,  quinine,  and  various  other 
remedies  may  at  times  be  used  to  allay  pain,  especially  the  pain 
of  neuralgia,  and  some  of  these  remedies  ought  to  be  used  in 
preference  to  opium  in  suitable  cases.  The  constant  current  is 
also  a  valuable  agent  for  assuaging  pain,  and  where  it  succeeds  it 
should  be  preferred  to  all  other  remedies,  inasmuch  as  its  use  is 
not  attended  with  any  evil  after  consequences. 

§  183.  Cold,  continuously  applied,  has  been  used  as  a  pal- 
liative for  the  removal  of  pain  in  neuralgia ;  while,  at  other 
times,  the  local  application  of  warmth  affords  relief,  probably  by 
producing  relaxation  of  the  tissues  in  which  the  nerve  fibres  are 
embedded. 

§  184,  Aconite  and  Veratrine,  applied  externally  in  the  form 
of  ointment  or  liniment,  have  also  been  found  efficacious  for  the 
removal  of  pain.  The  liniment  or  tincture  of  aconite  may  be 
painted  over  the  painful  nerve  ;  but  a  more  effectual  method 
is  to  rub  in  an  ointment  containing  a  grain  of  aconitine  to  the 
drachm  of  lard,  twice  a  day,  so  as  to  maintain  complete  numb- 
ness of  the  part  for  two  or  three  consecutive  days,  Veratrine 
and  atropine  ointment  may  be  used  in  the  same  way ;  but  the 
pharmacopoeia  ointment  of  the  former  is  too  strong. 

Continuous  pressure  over  a  nerve  has  been  employed  to 
arrest  its  conduction.  This  treatment  has  been  found  useful  in 
allaying  the  pain  of  neuralgia  and  in  arresting  motor  spasm. 

§  185.  Surgical  Operations. — When  a  nerve  is  simply  divided 
the  operation  is  called  neurotomy;  but  when  a  portion  is  dis- 
sected out  it  is  called  neurectomy.  Both  these  operations  have 
been  successfully  used  for  the  removal  of  pain  or  spasm.  Inter- 
ruption of  the  continuity  of  the  nerve  brings  immediate  relief, 
but  the  pain  or  spasm  is  apt  to  recur  when  the  divided  ends  of 
the  nerve  reunite.  Division  of  a  mixed  nerve  causes  paralysis 
of  the  muscles  supplied  by  it,  so  the  division  or  resection  of  a 
mixed  nerve  should  only  be  undertaken  under  the  most  pressing 
need. 


330  GENERAL  TREATMENT. 

§  186.  Stretching  of  the  affected  nerve  is  an  operation  which 
was  first  proposed  by  Nussbaum  for  the  cure  of  various  forms  of 
peripheric  neuroses,  and  its  employment  has  so  far  been  attended 
with  brilliant  success.  It  has  not  only  been  found  beneficial  for 
the  removal  of  pain  and  spasm,  but  it  appears  to  be  of  use  in  the 
treatment  of  tetanus  and  probably  other  centric  affections.  The 
treatment  of  various  other  distressing  symptoms,  such  as  cystitis, 
incontinence  of  urine,  painful  priapism,  and  bed-sores,  which  are 
apt  to  supervene  in  the  course  of  centric  diseases  of  the  nervous 
system,  will  be  described  in  the  special  part  of  the  work. 


BOOK    II. 


SPECIAL   PATHOLOGY  OF  THE  NERVOUS  SYSTEM. 


Part  I.— DISEASES  OF  THE  PERIPHERAL  NERVES. 


CHAPTER   I, 
ANATOMICAL    IXTEODUCTION. 


Each  spinal  nerve  arises  by  two  roots — an  anterior  which  con- 
tains the  efferent,  and  a  posterior  which  contains  the  afferent 
fibres  {Fig.  13,  a  a  and  p).  The  posterior  or  sensory  root 
possesses  a  ganglion  the  functions  of  which  are  not  accurately 
ascertained,  although  it  is  known  to  contain  the  trophic  centre 
of  the  afferent  fibres.  The  anterior  roots  are  sensitive,  but  that 
they  derive  their  sensibility  from  the  posterior  roots  is  shown  by 
the  fact  that  all  sensibility  ceases  on  the  latter  being  divided. 
The  sensibility  manifested  by  the  anterior  roots  has  been  called 
"  recurrent  sensibility,"  because  it  is  due  to  the  bending  back  of 
sensory  fibres  along  efferent  channels  {Fig.  21,  R). 

Fig.  21. 


Fig.  21  (from  Hermaim's  "Physiology"). — PE  and  A  are  respectively  the  poste- 
rior and  anterior  roots.  The  fibres  of  the  posterior  root  are  seen  to  terminate 
in  the  cutaneous  surface  C  ;  while  the  fibres  of  the  anterior  root  terminate  in 
a  muscle  M ;  R  represents  a  loop  of  sensory  fibres  passing  from  the  posterior 
roots  and  bending  backward  to  join  A,  the  anterior  root,  and  furnishing  it  with 
recurrent  sensibility. 


334 


ANATOMICAL  INTRODUCTION. 


§  187.  Structure  of  Nerves. — The  trunks  of  the  spinal  nerves 
consist  of: — 

(1)  Nerve  fibres  arranged  longitudinally  to  form  a  bundle 
{Fig.  22,  N).  The  fibres  within  a  bundle  are  separated  from 
each  other  by  numerous  connective  tissue  fibres,  and  flat- 
tened connective  tissue  cells,  which  together  constitute  the 
endoneuriuwh. 

(2)  Each  bundle  is  surrounded  by  a  special  sheath  of  con- 
nective tissue,  called  the  'perineurium  {Fig.  22,  P).  This 
sheath  possesses  a  lamellar  structure  ;  the  lamellae  consist  of 
bundles  of  fibrous  connective  tissue,  and  between  them  flattened 
connective  tissue  cells  are  observed,  lying  in  spaces  which 
constitute  more  or  less  continuous  lymph  channels.  The  lymph 
spaces  of  the  endoneurium  have  been  injected  by  Axel  Key 
and  Retzius  in  connection  with  the  lymph  spaces  of  the  peri- 
neurium. 

(3)  The  bundles  of  nerve  fibres  are  arranged  longitudinally, 
and  held  together  in  a  common  framework— ^Ae  epineurium 


Fig.  22. 


Fig.  22  (ffom  Klein's  "Atlas  of  Histology").      Transverse  SecMon  of  a  Nerve. 
N,  N,  Nerve  fibres  ;  P,  Perineurium  ;  EP,  Epiiiturium  ;  F,  Fat  cells. 


ANATOMICAL  INTRODUCTION,  335 

{Fig.  22,  EP).  This  framework  is  composed  of  bundles  of 
fibrous  connective  tissue,  arranged  as  larger  or  smaller  trabeculse, 
which  cross  each  other,  and  thus  form  a  more  or  less  dense 
plexus.  Ordinary  flattened  and  branched  connective  tissue  cells 
may  be  observed  between  the  connective  tissue  bundles ;  while 
fat  cells,  a  plexus  of  lymphatics,  and  the  blood-vessels  which 
supply  the  nerve  trunk,  are  embedded  in  the  substance  of  the 
epineurmrri. 

§  188.  The  Deep  Origin  and  Surface  Attachments  of  the 
Cranial  Nerves. 

The  first  or  olfactory  nerve  or  tract  must  be  regarded  as  a  constituent 
part  of  the  cerebrum  and  not  as  a  true  nerve.  It  is  attached  to  the  under 
surface  of  the  frontal  lobe  in  front  of  the  anterior  perforated  space,  by  means 
of  three  roots.  The  external  or  long  root  passes  outwards  and  backwards 
towards  the  posterior  border  of  the  Sylvian  fissure  where  it  disappears. 
The  middle  or  grey  root  consists  of  grey  matter  on  the  surface,  which  is 
prolonged  from  that  of  the  adjacent  part  of  the  frontal  lobe  and  the  anterior 
perforated  space  (Quain).  The  internal  or  short  root  is  composed  of  white 
fibres  which  may  be  traced  from  the  inner  and  posterior  part  of  the  frontal 
lobe.  The  outer  root  has  been  traced  to  the  island  of  Eeil,  the  optic  thala- 
mus, and  to  a  nucleus  in  the  substance  of  the  temporo-sphenoidal  lobe  in 
front  of  the  anterior  extremity  of  the  hippocampus.  It  has  been  supposed 
that  the  fibres  of  the  inner  root  are  connected  with  the  anterior  extremity 
of  the  gyrus  fornicatus,  or  cross  over  to  the  opposite  hemisphere.  The 
fibres  of  the  middle  root  are  said  by  some  to  join  those  of  the  inner  root, 
by  others  to  be  connected  with  the  corpus  striatum  (Quain). 

Optic  Nerve. — The  optic  nerves  of  the  two  sides  meet  each  other  at  the 
chiasma,  and  thence  proceed  backwards  roiuid  the  crura  cerebri  under  the 
name  of  the  optic  tracts.  Each  tract  terminates  by  two  roots ;  the  external 
and  larger  enters  the  external  geniculate  body,  which  is  connected  with  the 
anterior  pair  of  corpora  quadrigemina ;  and  the  internal  and  smaller  of  the 
two  passes  into  the  internal  geniculate  body,  but  its  fibres  seem  to  terminate 
in  the  anterior  corpora  quadrigemina  ;  at  least  the  consecutive  atrophy  of 
the  optic  nerves  and  tracts  which  follows  extirpation  of  the  globe  of  the 
eye  in  young  hares  does  not,  according  to  Gudden,  implicate  either  the 
internal  geniciilate  body  or  the  posterior  corpora  quadrigemina.  The 
fibres  of  the  external  root  do  not  all  terminate  in  the  external  geniculate 
body,  but  most  of  them  pass  onwards  to  reach  the  posterior  part  of 
the  optic  thalamus  or  pulvinar  (Fig.  23,  Pv).  According  to  Meynert, 
the  external  root  on  reaching  the  pxilvinar  becomes  divided  into  three 
bimdles :  (1)  a  superior  bundle,  which  passes  above  and  to  the  outside  of 
the  external  geniculate  body,  and  the  fibres  of  which  become  mixed  with 
those  of  the  stratum  zonale  of  the  optic  thalamus;   (2)  a  larger  bundle 


336 


ANATOMICAL   INTRODUCTION. 


which  passes  beneath  the  external  geniculate  body  and  penetrates  into  the 
optic  thalamus ;  (3)  a  bundle  which  penetrates  into  the  external  geniculate 
body  itself.  From  the  external  geniculate  body  and  pul\inar  issue  fibres 
which  form  part  of  the  posterior  portion  of  the  internal  capsule,  and 
constitute  the  deepest  layer  of  the  optic  radiations  of  Gratiolet;  these  fibres 
are  situated  below  the  tapetum  and  external  to  the  posterior  horn  of  the 
lateral  ventricle,  and  all  of  them  appear  to  terminate  in  the  cortex  of  the 
occipital  lobe.  Some  of  the  fibres  of  the  optic  tracts  may,  according  to 
StiUing,  be  traced  to  a  nucleus  in  the  cerebral  peduncle.  Immediately 
after  its  formation  at  the  external  geniculate  body  the  optic  tract  forms  a 
flattened  band,  which  winds  roimd  the  cerebral  pedimcle  and  tuber 
cinereum,  and  passes  under  the  lamina  cinereum,  where  it  imites  with  its 
fellow  of  the  opposite  side  to  form  the  optic  commissure  or  chiasma. 

A  grey  root  of  the  optic  nerves  has  been  described  in  addition  to  the 
fibres  derived  from  the  optic  tracts.  The  grey  root  is  a  layer  of  grey 
matter  which  is  derived  from  the  tuber  cinereum  and  lamina  cinerea,  and 
passes  downwards  and  forwards  to  spread  over  the  superior  surface  of  the 
optic  commissure. 

Fig.  23. 

Cn 


Fig.  23  (from  Henle's  "  Anatomic ") . — The  Corpora  Quadrigemina  viewed  from 
above  after  the  Cerebellum  has  been  removed. — Ccp,  Superior  Peduncle  of  the 
Cerebellum  ;  Ccq,  Peduncle  of  the  Cerebellum  to  the  Corpora  Quadrigemina ; 
Lg,  the  Valve  of  Vieussens  ;  Vma,  Velum  medulare  ant.;  Ccb,  Crus  Cerebri ; 
Cgm,  Internal  Geniculate  Body.  The  External  Geniculate  Body  is  situated 
close  to  the  outer  border  of  the  internal  one,  but  is  concealed  by  the  Thalamus. 
Bca,  Bcp,  Anterior  and  Posterior  Brachia  connecting  the  corpora  quadrigemina 
with  the  Pulvinar ;  Pv,  Pulvinar ;  Tho,  Thalamus  Opticus  ;  Cn,  Pineal  Gland ; 
IV,  The  rourth  or  Trochlear  Nerve. 


'  ANATOMICAL  INTRODUCTION.  337 

Chiasma. — The  disposition  of  the  fibres  of  the  optic  tracts  in  the 
commissiu'e  is  a  subject  of  much  controversy.  In  birds  and  fishes  a  com- 
plete crossing  of  the  fibres  apjpears  to  take  place,  the  fibres  of  the  tract  of 
one  side  passing  over  to  become  connected  with  the  retina  of  the  opposite 
side.  But  in  the  higher  animals,  including  man,  the  crossing  of  the  fibres 
appears  to  be  incomplete.  Pathological  records  seem  to  show  that  in  man 
the  fibres  of  the  oj)tic  tract  of  the  one  side  pass  to  the  outer  or  temporal 
half  of  the  retina  on  the  same  side  and  to  the  inner  or  nasal  half  of  the 
retina  of  the  opposite  side,  these  being  the  parts  of  the  retinse  which 
are  associated  in  their  actions.  But  this  simple  semi -decussation  of 
fibres  does  not  quite  account  for  several  known  pathological  facts.  In 
homonymous  hemianopsia,  for  instance,  the  point  of  fisation  or  central 
vision  is  always  spared  on  both  sides,  and,  if  disease  either  of  the  right  or 
of  the  left  tract  does  not  abolish  central  vision,  it  is  clear  that  the  macula 
lutea  of  each  eye  must  be  connected  with  the  cortices  of  both  hemispheres 
(Fig.  24).  Munk^  beheves  that  in  the  dog  there  are  three  visual  spheres 
in  the  cortices  of  the  occipital  lobes  corresponding  to  three  visual  areas  in 
the  retinae  {Figs.  25  and  26).  The  external  part  of  the  retina  of  the  left 
eye  is  connected  with  the  external  part  of  the  cortical  visual  centre  in  the 
left  hemisphere,  while  the  internal  and  central  portions  of  the  retina  of  the 
same  eye  are  respectively  connected  with  the  internal  and  central  portions 
of  the  visual  centre  of  the  opposite  or  right  hemisphere.  He  also  thinks 
that  the  upper  part  of  the  retina  is  connected  with  the  front,  and  the 
lower  part  with  the  posterior  aspect  of  the  visual  sphere  of  the  opposite 
side. 

Blood-vessels. — The  optic  tract  receives  at  its  origin  twigs  from  the 
arteries  distributed  to  the  corpora  quadrigemina  and  to  the  choroid  plexus. 

Fig.  24 


Fig.  24.  Schema  of  the  semi-decussation  of  the  fibres  of  the  Optic  Commissure. — 
b  a,  Left  Optic  Tract,  the  fibres  of  which  are  distributed  to  the  left  halves  of 
both  retinae ;  b'  a',  the  Right  Tract,  with  its  fibres  supplying  the  right  halves 
of  both  retinse.  Fibres  from  both  tracts  are  represented  as  terminating  in  the 
macula  lutea  of  each  side. 

'  Munk  (H.).    Ueber  die  Functionen  der  Grosshirnrinde.    Berl.,  1881.    p.  89. 
VOL.  L  W 


S38 


ANATOMICAL  INTKODUCTION. 


As  it  passes  under  the  cerebral  peduncle  to  the  chiasma  it  is  covered  by 
the  pia  mater,  from  which  it  derives  its  vascular  supply.  The  optic  nerve 
receives  its  arterial  supply  from  the  vessels  of  the  tract,  and  additional 
branches  from  the  posterior  or  short  ciliary  arteries. 

The  Arteria  Centralis  Retime  is  derived  from  the  trunk  of  the  ophthal- 
mic artery,  or  from  one  of  its  ciliary  or  muscular  branches,  and  enters  the 
nerve  about  three-eighths  of  an  inch  from  the  sclerotica.  Its  main  branches 
are  distributed  to  the  retina,  although  small  branches  communicate  with 
the  nutrient  vessels  of  the  optic  nerve. 


Fig.  25. 


Fig.  26. 


Fig.  25  (after  Mwak).— Horizontal  Sec- 
tion of  the  Visual  Cortical  Areas  made 
about  the  middle  of  the  region  A';  ihe 
posterior  segments  of  the  visual  areas 
are  shown  as  viewed  from  the  front ; 
the  eyes  are  cut  horizontally. 


Fig.  26  (after  Mmik).—Shoivs  the  Visual 
Spheres,  as  seen  from  above,  and  the 
two  retinte  from  behind,  the  middle 
portions  of  each  being  represented 
byO. 


Figs.  25  and  26. — A,  visual  area  of  right  side  (dotted) ;  a,  visual  area  of  left  side 
(lined) ;  A',  a',  the  portions  of  the  cortex,  extirpation  of  which  determines 
psychical  blindness  (deeply  shaded) ;  R,  r,  the  retinse,  the  dotted  and  lined 
portions  corresponding  to  the  similarly  marked  portious  in  the  visual  areas ; 
J3,  b,  auditory  areas,  contiguous  to  tlie  visual  spheres. 


ANATOMICAL   INTEODUCTION.  389 

The  third  and  fourth  nerves  {oculo-motorius  and  trochlearis)  arise  from  a 
grey  nucleus,  common  to  both,  beneath  the  floor  of  the  aqueduct  of  Sylvius. 
This  nucleus  communicates  with  the  corpora  quadrigemina,  and  through 
the  crus  with  the  lenticular  nucleus.  The  fourth  has  also  an  additional 
origin  from  the  locus  coeruleus. 

The  third,  or  oculo-motorius,  nerve  passes  downwards  and  forwards,  and 
pierces  the  under  and  inner  surface  of  the  crus  cerebri  in  the  interpedun- 
cular space,  close  to  the  upper  margin  of  the  pons.  From  this  point  the 
nerve  passes  forwards  and  outwards,  and  after  piercing  the  inner  layer  of 
the  dura  mater,  close  to  the  posterior  clinoid  process,  it  reaches  the  external 
wall  of  the  cavernous  sinus,  and  proceeds  forward  towards  the  sphenoidal 
fissure. 

The  fourth  nerve  turns  upwards  and  describes  a  semicircle  around  the 
aqueduct  of  Sylvius.  It  then  pierces  the  roof  of  the  aqueduct,  and,  after 
decussating  with  its  fellow,  crosses  to  the  opposite  side,  and  pierces  the 
crus  at  its  superior  and  external  border  (Fig.  23,  IV).  The  nerve  then 
passes  forwards  along  the  free  border  of  the  tentorium  to  reach  the 
external  wall  of  the  cavernous  sinus,  along  which  it  proceeds  to  reach  the 
sphenoidal  fissiire. 
^  The  fifth  or  trigeminal  nerve  arises  like  a  spinal  nerve  by  two  roots,  the 
one  motor  and  the  other  sensory.  The  latter  is  like  the  posterior  root  of 
a  spinal  nerve,  inasmuch  as  it  passes  through  a  ganglion — the  Gasserian 
ganglion. 

The  fibres  of  the  trigeminal  nerve  take  their  origin  from  several  nuclei : 
{a)  The  trigeminal  nucleus,  which  is  analagous  to  the  posterior  cornu  of  the 
grey  substance  of  the  cord,  and,  like  the  latter,  contains  only  small  gang- 
lionic cells.  It  is  situated  on  a  level  with  the  point  of  exit  of  the  nerve 
from  the  pons  and  towards  the  outer  part  of  the  floor  of  the  fourth  ventricle. 
(6)  An  ascending  root,  derived  from  the  posterior  column  of  the  cords  from 
a  portion  as  low  down  at  least  as  the  middle  of  the  neck.  The  fibres  spring 
from  the  grey  substance  of  the  posterior  cornu,  and  ascend  in  the  white 
posterior  columns.  At  the  side  of  the  medulla  the  fibres  run  very  super- 
ficially, and  constitute  the  tubercle  of  Rolando,  (c)  Descending  Roots  (1) 
from  a  large-celled  motor  root  in  the  neighbourhood  of  the  corpora  quadri- 
gemina, but  the  connections  of  this  root  with  the  ganglia  of  the  brain  are  not 
known ;  (2)  from  a  collection  of  large  vesicular  cells  (similar  to  the  cells  of 
the  spinal  ganglia)  at  the  side  of  the  aqueduct  of  Sylvius ;  and  (3)  from  the 
locus  cceruleus,  which  Hes  beneath  the  substantia  ferruginea  in  the  upper 
part  of  the  floor  of  the  fourth  ventricle,  {d)  Fibres  from  the  cerebellum, 
running  in  the  crm-a  cerebelli  and  corpora  quadrigemina. 

The  nerve  issues  from  the  side  of  the  pons  considerably  nearer  the 
i;pper  than  the  lower  border.  The  smaller  root  is  at  first  concealed  by  the 
larger,  and  is  placed  a  httle  higher  up.  Both  roots  are  directed  forwards 
side  by  side  to  the  middle  fossa  of  the  skull,  through  a  recess  in  the  dura 
mater  on  the  summit  of  the  petrous  part  of  the  temporal  bone,  at  the  apex 
of  which  the  Gasserian  ganglion  is  lodged  in  a  depression,  and  receives  om 


340  ANATOMICAL  INTRODUCTION. 

its  inner  side  filaments  from  the  carotid  plexus  of  the  sympathetic  nerve. 
The  smaller  root  passes  inside  and  beneath  the  ganglion  Tvdthout  communi- 
cating with  it,  and  outside  the  skiill  it  joins  the  lowest  of  the  three  trunks 
which  issue  from  the  ganglion. 

The,  Sixth  Nerve  (abditcens)  arises  from  a  large-celled  nucleus  at  the 
bottom  of  the  groove  in  the  floor  of  the  fomi:h  ventricle  at  the  junction  of 
the  medulla  oblongata  and  pons  near  the  fasciculus  teres.  This  nucleus 
communicates  with  the  nucleus  of  the  third  nerve  of  the  opposite  side 
(Duval).  After  the  emergence  of  the  sixth  nerve  from  the  medulla 
oblongata  it  passes  forwards  and  outwards  over  the  posterior  and  smooth 
quadrilateral  surface  of  the  sphenoid  bone  (dorsum  sellse),  and  enters  the 
cavernous  sinus,  between  the  internal  carotid  artery  and  the  fourth  nerve. 
It  then  passes  forwards  on  the  floor  of  the  sinus,  close  to  the  outer  side  of 
the  carotid  artery,  and  enters  the  orbit  through  the  sphenoidal  fissure 
between  the  heads  of  the  external  rectus  muscle. 

The  Seventh  or  F-adal  Nerve  is  derived  from  a  nucleus  similar  to  that  of 
the  sixth,  but  situated  somewhat  lower,  and  more  in  the  substance  of  the 
medulla  oblongata.  It  was  supposed  that  the  nerve  received  a  number  of 
fibres  from  the  nucleus  of  the  sixth,  but  the  observations  of  Gowers  appear 
to  have  disposed  of  this  statement.  A  descending  set  of  fibres  comes  from « 
the  lenticular  nucleus  of  the  opposite  side  of  the  body.  The  facial  nerves 
appear  on  each  side  of  the  medulla  at  the  inferior  margin  of  the  pons. 
Each  nerve  emerges  in  the  outer  margin  of  the  depression  between  the 
olivary  body  and  the  diverging  restiform  body,  the  auditory  nerve  lying  to 
its  outer  side.  The  nerve  passes  outwards  from  its  place  of  origin  to  enter 
the  internal  auditory  meatus,  and  at  the  bottom  of  the  meatus  it  passes 
into  the  aqueduct  of  Fallopius  and  follows  its  windings  to  the  lower  surface 
of  the  skull. 

The  Eighth  or  Auditory  Nerve  appears  at  the  lower  border  of  the  pons, 
external  to  and  a  Httle  below  the  facial  nerve.  The  intermediate  nerve  of 
Wrisherg  forms  a  separate  cord,  which  lies  between  the  auditory  and 
facial  nerves,  and  passes  along  with  them  into  the  internal  auditory  canal. 
The  -auditory  nerve  receives  fibres  from  four  independent  nuclei  which  lie 
on  a  level  with  the  broadest  portion  of  the  fourth  ventricle.  (1)  The  poste- 
rior median  nucleus  {Fig.  27,  VIII),  occupying  the  whole  space  included 
between  the  ala  cinerea  and  the  inferior  cerebellar  peduncle  up  to  the  ante- 
rior ijorder  of  the  striae  meduUares.  (2)  Anterior  median  acoustic  nucleus 
[Fig-  27,  VIII'),  occupying  the  external  angle  of  the  fourth  ventricle,  about 
the  middle  of  the  inferior  cerebellar  peduncle.  (3)  Posterior  lateral  acoustic 
nucleus  {Fig.  27,  VIII''')  hes  in  the  form  of  a  small  grey  nodule  between 
the  fasciculi  of  origin  of  the  acoustic  nerve  at  its  point  of  emergence  from 
the  medulla.  (4)  Anterior  lateral  acoustic  nucleus  {Fig.  27,  VIII'"'),  which 
appears  to  be  a  prolongation  of  the  posterior  lateral  nucleus,  and  is  wedged 
in  between  the  middle  peduncle  of  the  cerebellum  and  the  flocculus. 

On  reaching  its  point  of  junction  with  the  medulla  and  pons  the  auditory 
nerve  divides  into  a  posterior  and  an  antenor  branch,  the  former  winding 


ANATOMICAL   INTRODUCTION. 


341 


round  the  restiform  body  to  become  connected  by  means  of  the  strise 
acousticae  with  the  posterior  median  nucleus,  and  the  latter  passing  through 
the  substance  of  the  restifonn  body  to  be  connected  with  the  apex  of  the 
posterior  median  nucleus  and  the  anterior  median  nucleus.  Other  fibres 
pass  directly  into  the  posterior  lateral  nucleus.  Some  of  the  fibres  of  this 
division  join  the  anterior  lateral  acoustic  nucleus ;  these  fibres  have  been 
traced  through  the  cerebellum  as  far  as  the  superior  vermiform  process. 

Tht  Ninth  or  Glosso-pharyngeal  Nerve. — The  nucleus  of  the  glosso- 
pharyngeal nerve  is  not  separated  by  a  distinct  boundary  from  that  of  the 
vagus,  but  the  former  hes  somewhat  more  superficially  than  the  latter 
{Fig.  27,  IX). 

Fig.   27. 


Fig.  27  (after  Erb).  View  of  the  Posterior  Surface  of  the  Medulla,  the  roof  of  the 
fourth  ventricle  being  removed  to  show  the  rhomboid  sinus  clearly. — The  left 
half  of  the  figure  represents  : — Cm,  funiculus  cuneatus,  and(/,  funiculus  gracilis  ; 
O,  obex  ;  sp,  nucleus  of  the  spinal  accessory ;  ^j,  nucleus  of  pneumogastric, 
p  -r  sp,  ala  cinerea ;  R,  restiform  body ;  XII',  nucleus  of  the  hypoglossal ;  t,  funi- 
culus teres ;  a,  nucleus  of  the  acousticus ;  m,  strise  medullares  ;  s,  inferior  acoustic 
nuclexis ;  1,  2,  and  3,  middle,  superior,  and  inferior  cerebellar  peduncles  respec- 
tively; /,  fovea  anterior;  4,  eminentia  teres  (genu  nervi  facialis);  5,  locus 
coeruleus.  The  right  half  of  the  figure  represents  the  nerve  nuclei  diagramati- 
cally ;  V,  motor  trigeminal  nucleus  ;  V,  median,  and  V",  inferior  sensory 
trigeminal  nuclei ;  VI,  nucleus  of  abducens ;  VII,  facial  nucleus ;  VIII,  pos- 
terior median  acoustic  nucleus  ;  VIII'  anterior  median,  VIII"  posterior  lateral, 
VIII'"  anterior  lateral  acoustic  nuclei ;  IX,  glosso-pharjTigeal  nucleus  ;  X,  XI, 
and  XII,  nuclei  of  vagus,  spinal  accessory,  and  hypoglossal  nerves  respectively. 
The  Roman  numerals  at  the  side  of  the  figure,  from  V  to  XII,  represent  the 
corresponding  nerve  roots. 


342 


ANATOMICAL   INTRODUCTION. 


The  Tenth  Nerve  {Par  Vagum-,  Fneumogastric  or  Vagus). — The  vagus 
arises  from  a  nucleus  situated  in  the  lower  half  of  the  floor  of  the  fourth 
ventricle  (Fig  28,  X),  and  from  another  in  the  substance  of  the  medulla 
oblongata,  near  the  olivary  body.  The  nerve  emerges  from  the  medulla 
oblongata,  between  its  lateral  column  and  the  restiform  body.  Its  roots, 
between  twelve  or  fifteen  in  number,  lie  beneath,  and  in  a  hne  with  the  roots 
of  the  glosso-pharyngeal  nerve.  The  filaments  of  the  roots  are  arranged  in 
a  flat  fasciculus,  which  is  directed  outwards,  with  the  glosso-pharyngeal 
nerve,  across  the  flocculus  to  the  jugular  foramen. 

The  Eleventh,  or  Spinal  Accessory  Nerve,  consists  of  two  branches— an 
internal,  derived  from  the  medulla,  which  joins  the  trunk  of  the  pneumo- 
gastric,  and  an  external  branch  derived  from  the  cord,  which  is  distributed 

Fig.  28. 


Fig.  28  (after  Erb). — Transparent  lateral  view  of  the  Medulla,  showing  the  relative 
positions  of  the  most  important  nuclei ;  right  half  of  the  medulla,  seen  from  the 
surface  of  section ;  the  parts  that  lie  closer  to  this  surface  are  deeper  shaded. 
JDiagramatic.  Py,  pyramidal  tract ;  Pi/,  Kr,  decussation  of  pyramids ;  O,  olivary 
body;  Os,  superior  olivary  body;  V,  motor,  V,  middle  sensory,  V"^  inferior 
sensory  nucleus  of  trigeminus ;  VI,  nucleus  of  abducens ;  G/,  genu  facialis 
nervi ;  VII,  nucleus  facialis ;  VIII,  posterior  median  acoustic  nucleus ;  IX, 
glosso-pharyngeal  nucleus ;  X,  nucleus  of  vagus ;  XI,  nucleus  of  the  acces- 
sorius ;  XII,  hypoglossal  nucleus ;  'Kz,  nucleus  of  the  funiculus  gracilis ;  Kv, 
trigeminus  root ;  E.VI,  root  of  the  abducens ;  RVII,  root  of  the  facialis. 


ANATOMICAL   INTRODUCTION.  843 

to  the  sterno-mastoid  and  trapezius  muscles.  This  nerve  arises  by  a  series 
of  roots,  the  upper  of  which  are  attached  to  the  side  of  the  medulla  below 
those  of  the  pnemnogastric,  while  the  remainder  arise  from  the  lateral 
column  of  the  cord  as  low  down  as  the  sixth  or  seventh  pair  of  cervical 
nerves.  The  upper  roots  pass  inwards  to  a  nucleus  which  lies  on  each 
side,  at  the  back  of,  and  close  to  the  central  canal.  The  spinal  roots  pass 
through  the  lateral  column  of  the  cord,  and  enter  the  grey  substance 
midway  between  the  anterior  and  posterior  cornua. 

The  Twelfth  or  Hypoglossal  Nerve. — The  nucleus  of  the  hypoglossal  con- 
sists of  a  column  of  large  branching  nerve  cells,  which  lies  close  to  and  in 
front  of  the  central  canal,  as  low  as  the  decussation  of  the  pyramids.  When 
the  canal  opens  into  the  floor  of  the  fourth  ventricle  the  nucleus  comes  to 
the  surface,  and  causes  a  prominence  close  to  the  middle  line,  a  little  above 
the  point  of  the  calamus  scriptorius. 

Bundles  of  fibres  issue  from  the  nucleus,  and  pass  forwards  through  the 
inner  side  of  the  olivary  body,  to  form  a  series  of  fine  roots  in  the  furrow 
between  the  anterior  pjTamid  of  the  medulla  and  the  olivary  body.  The 
roots  are  collected  into  two  bundles,  which  converge  to  the  anterior  condy- 
loid foramen  of  the  occipital  bone.  These  bundles  perforate  the  dura  mater 
separately  within  the  foramen,  and  are  joined  into  one  trunk  after  they 
have  passed  through  it. 

The  subjoined  diagrams  (Figs.  29  and  30)  show  the  siu"face  attachments 
of  the  cranial  nerves,  and  their  course  through  the  skull,  so  clearly  as  to 
render  unnecessary  a  detailed  reference  to  them  in  the  test. 


344: 


ANATOMICAL  INTRODUCTION. 


Fig.  29. 


Fig.  29  (from  Renin's  "  Anatomie").  The  Base  of  the  Brain  and  adjoining  part  of 
the  Spinal  Cord.— The  Cranial  Nerves  are  represented  by  the  corresponding 
Roman  letters  from  I  to  XII.  VII',  Portio  intermedia  of  the  seventh ;  nc  I, 
First  cervical  nerve. 


ANATOMICAL   INTRODUCTION. 

Fig.  30. 


345 


Fig  30  (from  Henle'a  "  Anatomie").  Internal  View  of  the  £ase  of  the  Skull,  showing 
the  Places  of  Exit  of  the  Cranial  Nerves.-The  Nerves  are  represented  by  the 
corresponding  Roman  numerals,  from  I  to  XII.  VS  V%  y^  the  first,  second, 
and  third  divisions  of  the  fifth  respectively.  V*,  the  Gasserian  Ganguon.  Ihe 
sensory  root  is  cut  short  in  order  to  show  the  motor  root  of  the  fifth  as  it  passes 
under  the  gangUon.  The  dura  mater  is  removed  on  the  right  side,  and  the  u  erves 
may  be  followed  to  the  various  foramina  through  which  they  pass  from  the  skull. 
The  Nerves  III,  IV,  V,  and  VI  may  be  seen  passing  over  the  convexity  of  the 
curve,  which  the  internal  carotid  artery  makes  in  the  groove  of  the  sphenoia 
bone.  1,  Anterior  clinoid  process;  2,  Posterior  cUnoid  process;  3,  irans verse 
section  of  the  internal  carotid  artery.  H,  Peduncle  of  the  pitmtary  body; 
t,  anterior  body  of  the  divided  tentorium  ;  fcb,  Falx  Cerebelli. 


346 


CHAPTEE   II. 


GENERAL    DISEASES    OF    THE    PERIPHERAL    NERVES. 

(I.)-  HYPEREMIA  OF  THE  NEE VES— CONGESTION". 

The  symptoms  caused  by  freezing  of  the  ulnar  nerves  were  first, 
described  by  Waller,^  and  Weir  Mitchell^  has  employed  artificial 
freezing  and  thawing  of  exposed  nerves  as  a  means  of  investi- 
gating the  symptoms  of  hypersemia  of  the  nerves.  After 
thawing,  the  nerves  presented  more  or  less  extensive  rosy  or 
dark-red  injections,  and  appeared  somewhat  swollen,  and  after 
the  prolonged  application  of  cold  punctiform  extravasations  of 
blood  were  found  between  the  nerve  fibres. 

§  189.  Symptoms.— The  symptoms  due  to  freezing  are  pain, 
anaesthesia,  paralysis,  increase  of  temperature,  and  augmented 
perspiration  in  the  region  of  distribution  of  the  nerve.  In  the 
thawed  portion  a  very  painful  sensation  is  felt,  which  in  the 
case  of  the  ulnar  nerve  spreads  backwards  to  the  brachial  plexus, 
and,  in  some  instances,  may  even  produce  vertigo  and  a  feeling  of 
faintness.  The  symptoms  which  follow  the  thaw  are  hypersesthesia 
and  a  feeling  of  numbness  and  formication,  and  partial  loss  of 
power,  in  the  region  of  distribution  of  the  affected  nerve,  along 
with  a  sense  of  fulness,  and  slight  swelling  of  the  affected  part, 
but  no  notable  elevation  of  temperature. 

(IIO-INFLAMMATION   OF  NERVES- NEUEITIS. 
The  frequency  with  which  neuritis  occurs  is  not  yet  definitely 

^  Waller  (A.).  *'  On  the  sensory,  motot^,  aiid  Vaso-motoiy  Bympttans  resulting 
from  refrigeration  of  the  ulnar  nerve."  Proceedings  of  the  Royal  iSociety  of  London, 
Vol.  XI.,  1861,  p.  436  ;  and  Vol.  XII.,  1863,  p.  89. 

^  Mitchell  (S.  Weir).  Injuries  of  Nerves  and  their  consequences.  Lond.,  1872. 
p.  56. 


GENERAL  DISEASES  OF  THE  PERIPHERAL  NERVES.         347 

settled,  but  it  is  by  no  means  a  rare  disease,  and  in  recent  years 
considerable  additions  have  been  made  to  our  knowledsfe  of  the 
subject  by  which  the  sphere  of  neuritis  has  been  greatly  extended. 
It  is,  however,  probable  that  Remak^  had  gone  too  far  when  he 
stated  it  as  his  belief  that  all  forms  of  sciatica  were  caused  by 
neuritis. 

Etiology. -^Wonuds,  contusions,  rupture,  laceration,  and  ex- 
posure to  cold  and  wet,  are  the  best  known  and  most  frequent 
causes  of  neuritis.  Strong  compression  of  a  nerve,  sudden  and 
violent  muscular  movements,  severe  concussions,  and  various 
other  injuries  may  also  cause  the  disease.  Neuritis  may  also 
result  from  extension  of  inflammation  from  the  surrounding 
tissues  and  organs.  It  has  been  shown  by  Beau^  that  pleurisy, 
pleuro-pneumonia,  and  tuberculosis  of  the  lungs  may  cause 
inflammation  of  the  intercostal  nerves  in  the  posterior  portion 
of  their  course  where  they  are  in  contact  with  the  costal  pleura. 
Paralysis  of  some  of  the  muscular  groups  supplied  by  the  sciatic 
nerve  may  be  caused  by  extension  of  inflammatory  action  to  one 
or  more  of  the  cords  of  the  sacral  plexus  from  a  pelvic  abscess,^ 
uterine  disease,  or  inflamed  haemorrhoids.*  Acute  and  chronic 
rheumatism  of  the  joints,  especially  of  the  shoulder  joint,  not 
unfrequently  lead  to  neuritis.  Caries  of  bones,  inflamed  tendinous 
sheaths,  and  malignant  growths  may  be  mentioned  as  other  causes 
of  the  disease.  Neuritis  frequently  becomes  developed  after  acute 
diseases,  such  as  typhoid  fever,  the  acute  exanthemata,  and 
diphtheria,  and  it  is  also  often  caused  by  chronic  diseases,  such 
as  chronic  rheumatism  and  syphilis.^  Recent  researches  have 
proved  that  the  peripheral  nerves  undergo  morbid  changes 
indicative  of  inflammation  in  chronic  poisoning  by  lead,  and  it 
is  very  probable  that  similar  changes  may  be  caused  by  other 
metallic  poisons,  such  as  copper  and  arsenic.  Inflammation  of 
the  nerves  is  also  met  with  in  lepra  ansesthetica,  herpes  zoster, 
and  various  other  cutaneous  affections. 


»  See  Eemak.    Allg.  med.  Central-Zeitung.    Bd.  XXIX.,  1860,  p.  93. 
^Beau  (J.-H.-S.).     "De  la  nevrite  et  de  la  n^vralgie  intercostales."    Archiv. 
G^ner.  de  Me'd.,  4e  Serie,  Tome  XIII.,  1847,  p.  161. 
^  Adams  (W.).     The  Lancet.    Vol.  II.,  1880,  p.  699. 

*  Remak.     Op.  cit.,  p.  165. 

*  Buzzard  (T.).     "Cases  of  neuritis,  syphilitic  and  rh'.umatic."    The  Lancet, 
Vol.  I.,  1879,  p.  289. 


348  GENERAL   DISEASES   OF 

Neuritis  sometimes  appears  in  the  absence  of  any  recognisable 
cause,  and  then  we  must  speak  of  its  origin  as  spontaneous  and 
regard  it  as  idiopathic. 

§  190.  Symptoms. 

Neuritis  presents  several  clinical  varieties.  The  inflammation 
may  be  limited  to  one  nerve  trunk  and  its  branches,  or  it  may 
invade  neighbouring  nerve  trunks  by  continuity;  it  is  then 
called  local  or  simple  neuritis.  This  form  of  the  disease  may 
be  subdivided  into  (1)  acute,  and  (2)  chronic  simple  neuritis. 
At  other  times  inflammation  attacks  almost  simultaneously  nerves 
situated  in  totally  difl'erent  parts  of  the  body,  and  successively 
invades  a  larger  and  larger  number,  generally  beginning  at  the 
peripheral  segments  and  extending  towards  the  centres ;  this 
affection  constitutes  a  third  variety,  which  may  be  called  pro- 
gressive multiple  neuritis. 

(1)  Acute  Simple  Neuritis  comes  on  shortly  after  exposure 
to  one  or  other  of  the  causes  of  the  disease.  It  is  ushered  in  by 
a  well-marked  feeling  of  chilliness,  or  by  an  actual  rigor,  accom- 
panied by  headache,  sleeplessness,  and  smart  fever.  In  inflam- 
mation of  a  mixed  or  sensory  nerve  the  patient  experiences 
severe  and  almost  intolerable  pain,  which  occurs  in  the  absence  of 
all  external  causes.  The  pain  is  usually  limited  to  the  region, 
supplied  by  the  affected  nerve,  but  when  very  intense  it  may 
radiate  to  the  regions  of  other  nerves  of  the  same  plexus,  and 
even  into  more  remote  nerve  territories.  The  pain  is  generally 
intense,  deep-seated,  tearing,  boring,  or  burning,  and  it  is 
described  as  almost  continuous.  Perfectly  free  intervals,  such 
as  occur  in  neuralgia,  are  rare  in  neuritis,  although  the  symptoms 
are  characterised  by  remissions  and  paroxysmal  exacerbations, 
the  latter  being  specially  apt  to  occur  at  night.^  Every  move- 
ment of  the  limb  augments  the  sufferings  of  the  patient,  and 
pressure  over  the  affected  nerve  causes  intense  pain,  which  radiates 
from  it  in  all  directions.  The  track  of  the  inflamed  nerve  is 
sometimes  indicated  by  a  red  line,  like  that  which  occurs  during 
inflammation  of  a  superficial  lymphatic  vessel,  and  the  skin  over 

^  See  Nothnagel  (H.).  "  On  neuritis  in  relation  to  its  diagnosis  and  pathology." 
Volkmann's  collection  of  German  clinical  lectures,  New  Syd.  Soc,  2nd  series. 
Lend.,  1877.    p.  201. 


THE   PERIPHERAL   NERVES.  349 

the  whole  region  of  its  distribution  is  extremely  sensitive  to  the 
slightest  contact,  while  the  patient  complains  of  numbness  and 
formication  in  this  area.  In  acute  neuritis,  however,  the  exuda- 
tion soon  compresses  the  nerve  fibres,  and  hypersesthesia  gives 
place  to  ansesthesia  of  the  skin  in  the  affected  nerve  territory. 
Muscular  twitchings  and  spasms  may  be  present  in  the  early 
stage  of  the  disease,  but  these  are  soon  replaced  by  paralysis  of 
the  muscles  to  which  the  nerve  is  distributed.  The  degree  of 
paralysis  varies  according  to  the  severity  of  the  inflammation, 
but  in  all  aggravated  cases  the  muscles  undergo  rapid  atrophy, 
and  manifest  "  the  reaction  of  degeneration."  In  excitable 
patients  an  attack  of  neuritis  may  be  attended  by  slight 
delirium,  and  an  emotional  condition  is  sometimes  induced 
which  may  be  mistaken  for  an  attack  of  hysteria. 

(2)  Chronic  Simple  Neuritis. — Chronic  neuritis  occurs  either 
as  a  sequel  to  an  acute  attack,  or  it  arises  insidiously  with  obscure 
symptoms,  which  gradually  or  suddenly  attain  great  intensity. 
Pain  is  the  earliest  and  most  constant  symptom ;  it  varies  con- 
siderably in  character  and  intensity,  being  sometimes  dull  and 
tensive,  at  otber  times  of  a  lancinating  or  tearing  character  and 
radiating  towards  the  periphery.  The  pain  is  continuous, 
although  frequently  interrupted  by  paroxysmal  exacerbations, 
which  generally  occur  at  night  and  prevent  sleep.  It  is  increased 
by  every  kind  of  exertion  and  movement,  and  by  everything 
which  excites  the  activity  of  the  heart.  The  patient  also  com- 
plains of  numbness  and  formication,  and  of  unpleasant  pricking 
sensations,  when  the  skin  is  touched  or  struck.  Ansesthesia, 
varying  in  degree  from  slight  blunting  to  complete  loss  of  all 
forms  of  sensibility,  is  observed  in  the  second  stage  of  the 
affection. 

Symptoms  of  motor  irritation,  such  as  tension  of  the  muscles, 
tremors,  sudden  contractions,  and  occasionally  violent  tonic 
cramps  and  persistent  contractures,  are  present  in  the  early 
stage  of  the  disease,  and  these  are  succeeded  by  paralytic 
phenomena. 

Various  reflex  phenomena  are  commonly  observed  during 
the  first  or  irritative  stage  of  the  disease.  Reflex  cramp  is 
sometimes  so  violent  that  the  nails  of  the  fingers,  for  example, 
may  bury  themselves  in  the  skin  of  the  hand,  from  spasm  of  the 


350  GENERAL  DISEASES  OF 

flexors  ;  spasms  of  the  facial  muscles  are  met  with  when  the 
fifth  nerve  is  affected,  and  even  the  sphincter  of  the  iris  and 
ciliary  muscle  may  be  the  subjects  of  spasm  when  the  ophthalmic 
branch  is  implicated. 

The  affected  nerve  may  become  swollen  to  such  an  extent  that 
when  it  occupies  a  superficial  position  it  can  be  felt  as  a  con- 
tinuously thickened  cord.  In  other  cases  the  thickening  occurs 
at  certain  intervals,  and  then  fusiform  or  moniliform  swellings 
inay  be  felt  in  the  course  of  the  nerve  (neuritis  nodosa).  The 
nerve  is  always  sensitive  to  pressure,  and  pressure  made  upon 
one  of  the  swollen  portions  occasions  eccentric  pains  and 
formication. 

With  regard  to  the  electrical  relations,  the  excitability  for  both 
currents  may  remain  normal  or  be  even  increased  in  slight  cases 
caused  by  a  moderate  degree  of  compression  of  a  nerve;  but  in 
rheumatic,  and  syphilitic  cases,  and,  indeed,  in  all  aggravated 
forms  of  the  disease  the  muscles  undergo  atrophy  and  manifest 
the  "  reaction  of  degeneration." 

Trophic  disturbances  in  the  skin  and  nails,  and  swelling  and 
stiffness  of  the  joints,  have  frequently  been  observed  in  neuritis, 
but  these  need  not  detain  us  at  present  as  they  have  already 
been  described.  Hysterical  or  epileptic  convulsions,  as  well  as 
traumatic  trismus  and  tetanus,  may  be  induced  by  neuritis. 

(8)  Progressive  Multiple  Neuritis. — This  affection  is  usually 
ushered  in  by  more  or  less  fever ;  the  patient  soon  complains  of 
tingling  pains,  along  with  feelings  of  coldness  and  numbness  in 
the  feet  and  hands,  either  simultaneously  or  successively,  the 
territory  of  the  ulnar  nerve  being  peculiarly  liable  to  be  pro- 
foundly affected  at  an  early  period  of  the  disease.  Pressure 
over  circumscribed  spots  of  the  nerves  causes  great  pain,  which 
radiates  towards  the  periphery,  and  both  the  skin  and  the  muscles 
in  the  area  of  distribution  of  the  affected  nerves  are  so  extremely 
sensitive  to  pressure  that  the  patient  avoids  any  movement  of  the 
limbs,  and  complains  bitterly  of  the  slightest  touch  or  of  passive 
movements.  Alongside  this  hypersesthesia  to  pressure  there  is 
well-marked  anaesthesia  of  certain  forms  of  sensibility.  The 
tactile  sensibility  is  indistinct,  the  patient  is  unable  to  localise 
accurately,  when  his  eyes  are  closed,  a  point  touching  the  skin, 
and  cannot  distinguish  two  points  as  separate  until  they  are  far 


THE   PERIPHERAL  NERVES.  351 

removed  from  one  another.  In  the  early  stage  of  the  disease  it 
is  somewhat  difficult  to  distinguish  whether  the  motionless  con- 
dition of  the  limbs  arises  from  the  reluctance  of  the  patient  to 
move  them  for  fear  of  provoking  the  pain,  or  from  decided  motor 
paralysis.  Soon,  however,  distinct  paralysis  sets  in,  accompanied 
by  a  rapid  atrophy  of  the  affected  muscles  ;  it  begins  in  the  small 
muscles  of  the  hands  and  feet,  gradually  spreads  upwards,  and 
successively  invades  the  larger  muscles  of  the  limbs  and  those 
of  the  trunk,  while  in  some  cases  the  muscles  of  the  bladder  and 
rectu-m  are  involved.  The  paralysis  is  more  pronounced  in  the 
small  muscles  of  the  hands  and  in  the  extensors  of  the  forearm 
than  in  any  other  part  of  the  body ;  these  muscles  undergo  rapid 
atrophy,  and  the  fingers  and  hand  assume  distorted  positions 
similar  to  the  claw-hand  of  progressive  muscular  atrophy.  The 
electrical  reactions  of  the  paralysed  muscles  have  not  been  accu- 
rately ascertained,  but  Leyden  has  met  with  the  "reaction  of  de- 
generation" in  muscles  which  had  undergone  pronounced  atrophy. 
Some  of  the  cutaneous  reflexes  may  be  normal,  while  others  are 
variously  altered.  The  plantar  reflex  is  absent  in  the  advanced 
stage  of  the  disease ;  even  at  first  it  is  absent  to  slight  stimulation, 
but  a  strong  stimulus  provokes  an  exaggerated  reaction.  The 
tendon-reactions,  and  more  especially  the  patellar-tendon  reaction, 
appear  to  be  abolished  at  an  early  period  of  the  disease  (Grainger 
Stewart).  The  affected  nerves  are,  as  already  mentioned,  painful 
on  pressure  of  particular  points,  and  at  times  the  nerve  may  be  felt 
to  be  distinctly  swollen  at  these  points ;  while  in  some  cases  the 
nerve  may  be  the  seat  of  an  oedematous  swelling  of  considerable 
size,  forming  a  marked  feature  of  the  case,  and  greatly  aiding 
the  diagnosis  (Leyden).  The  trophic  disorders  observed  consist, 
besides  the  atrophy  of  the  muscles  already  described,  of  altera- 
tions of  the  nails,  which  sometimes  become  brittle,  cracked, 
strongly  curved,  and  of  a  yellowish  or  brownish  colour ;  and  of  an 
increa.sed  development  of  hair,  or  in  some  cases  disappearance  of 
the  hair  from  some  spots  of  the  skin,  the  skin  of  the  fingers  being 
especially  liable  to  become  hairless  and  glossy.  Patches  of  the 
skin  are  liable  to  become  of  a  red  or  bluish  colour  from  vaso- 
motor changes,  and  the  subcutaneous  tissue  may  also  become 
decidedly  oedematous. 

Duration,  Course,  and  Termination. — Acute  neuritis   lasts 


852  GENERAL  DISEASES   OF  ' 

for  a  few  days  or  weeks,  and  either  terminates  in  recovery  or 
passes  into  the  chronic  form.  Chronic  neuritis  is  of  very  uncer- 
tain, but  always  of  protracted  duration,  and  even  the  slighter 
forms  do  not  recover  before  the  lapse  of  weeks  or  months. 
Traumatic  forms  are  least  complicated  when  reunion  has 
taken  place;  disturbances  of  sensibility  first  disappear,  motor 
power  then  gradually  returns,  and  ultimately  the  atrophy  and 
any  secondary  disturbances  of  nutrition  that  may  be  present 
gradually  vanish,  and  recovery  is  complete.  Idiopathic  forms 
of  neuritis,  those  dependent  on  rheumatic  causes,  or  which  occur 
after  acute  diseases,  are  less  favourable,  and  may  last  for  months 
or  years,  and  in  some  cases  never  entirely  disappear.  Persistent 
neuralgia  and  ansesthesia,  debility,  and  even  complete  motor 
paralysis,  not  unfrequently  result  from  chronic  neuritis,  but 
improvement  and  recovery  may  take  place  even  in  these  cases 
at  a  late  period  of  the  disease.  The  course  and  symptoms  of 
neuritis  vary  according  as  the  nerves  affected  are  purely  sensory, 
purely  motor,  or  mixed,  but  the  symptoms  in  each  case  may  be 
deduced  from  the  general  description  which  has  already  been 
given. 

Although  simple  neuritis  cannot  be  regarded  as  a  true  progres- 
sive disease,  yet  it  manifests  a  disposition  to  propagate  itself 
along  the  nerve  in  a  centripetal  direction,  and  then  to  extend  to 
nerves  lying  at  a  higher  plane  and  to  the  spinal  cord.  Leyden^ 
is  inclined  to  refer  the  myelitis,  which  occurs  after  affections  of 
the  urinary  and  other  pelvic  viscera,  to  a  lumbo-sacral  ascending 
neuritis,  which  extends  to  the  spinal  cord,  and  Friedreich^  be- 
lieves that  neuritis  is  the  middle  term  between  primary  myositis 
and  what  he  considers  as  the  secondary  affection  of  the  spinal 
cord  in  progressive  muscular  atrophy.  He  also  refers  nume- 
rous other  morbid  processes  either  to  ascending  or  descending 
neuritis. 

In  its  onset  multiple  progressive  neuritis  is  essentially  an  acute 
affection,  considerable  sensory  and  motor  disturbances  being 
established  in  the  course  of  a  few  days.  In  its  further  progress 
the  affection  becomes  chronic,  and  any  change  which  takes  place 

» Leyden.  "  Ueber  Keflexlahmungen."  Volkmann's  Klin.  Vortrage,  1870, 
No.  2,  p.  1. 

'  Friedreich.     Ueber  progressive  Muskel  atrophic.     1873. 


THE  PERIPHERAL  NERVES.  353 

either  by  way  of  amendment  or  extension  of  the  disease  may 
occupy  many  weeks.  After  from  nine  to  eighteen  months  com- 
plete recovery  may  take  place,  or  the  recovery  may  be  partial, 
the  muscles  supplied  by  the  ulnar  nerve  remaining  sometimes 
permanently  disabled.  The  disease  sometimes  terminates  in 
death  from  implication  of  the  intercostal  and  bulbar  nerves,*  but 
the  fatal  result  is  often  caused  by  some  complication,  as  chronic 
nephritis  (Leyden),  or  an  intercurrent  affection,  as  pneumonia 
(Grainger  Stewart)  or  tuberculosis  (Eisenlohr). 

§191,  Morbid  Anatomy. 

(1)  Acute  Simple  Neuritis  and  Perineuritis. — Inflammation 
of  a  nerve  may  begin  in  the  nerve  fibres  themselves,  and  it  then 
constitutes  a  true  neuritis;  or  it  may  begin  in  the  sheath  or 
epineurium,  when  it  constitutes  perineuritis.  But  inasmuch  as 
the  different  layers  of  the  sheath  of  the  nerve  are  rapidly  invaded 
by  the  inflammatory  process  when  the  nerve  fibres  are  primarily 
affected,  and  the  nerve  fibres  are  readily  implicated  when  the 
process  begins  in  the  sheath,  it  is  not  always  easy  in  practice  to 
distinguish  between  neuritis  and  ^perineuritis.  In  acute  neuritis 
or  perineuritis  the  vessels  become  enlarged  and  distended,  and 
the  nerve  trunk  swollen  from  serous,  gelatinous,  or  fibrinous 
exudation.  As  the  disease  proceeds,  the  medulla  coagulates, 
and  both  the  interannular  nuclei  of  the  nerve  fibres  and  the 
connective  tissue  nuclei  undergo  proliferation.  During  the  stage 
of  serous  effusion  the  nerve  may  be  unusually  soft,  but  when  the 
effusion  becomes  fibrinous  it  becomes  abnormally  firm. 

The  further  progress  of  the  case  depends  upon  the  acuteness 
of  the  process  and  the  length  of  time  which  elapses  before  the 
inflammatory  action  is  arrested.  If  the  inflammation  subside 
at  an  early  date  the  effusion  is  absorbed  before  there  is  any 
destruction  of  the  nerve  fibres,  and  the  healthy  condition  is 
readily  re-established.  If  the  inflammatory  action  is  very  acute 
and  severe,  both  white  and  red  blood  corpuscles  escape  from  the 
vessels,  the  colour  of  the  nerve  becomes  yellow  or  brownish  red, 
its  tissue  is  infiltrated  with  sanguineous  pus,  while  abscesses  may 
form  around  its  trunk  (Mitchell),  and  the  entire  structure  may 
become  completely  disintegrated. 

'  Dumenil.     Gaz.  Hebd.,  1866,  p.  51  et  seq. 
VOL.  I.  X 


354  GENERAL  DISEASES   OF 

(2)  Chronic  Simple  Neuritis  and  Perineuritis. — When  the 
process  has  passed  from  the  acute  into  the  chronic  form,  or  has 
been  chronic  from  the  beginning,  the  trunk  of  the  nerve  becomes 
irregularly  vascular,  and  is  enlarged  in  some  places  and  atrophied 
at  others.  The  sheath  of  the  nerve  becomes  thickened,  fibrous, 
and  resisting,  while  it  is  frequently  adherent  to  the  adjacent 
tissues.  In  cases  of  perineuritis  the  nerve  fibres  are  compressed 
by  the  exudation  and  disappear  after  a  time,  so  that  the  structure 
of  the  nerve  is  supplanted  by  a  band  of  connective  tissue. 

(3)  Progressive  Multi'ple  Neuritis. — This  disease  was  first 
described  by  Dumenil^  in  1864,  and  two  years  later  he  had  an 
opportunity  of  making  a  post-mortem  examination  of  a  case 
which  came  under  his  observation,  and  found  extensive  degenera- 
tion of  nerves,  anterior  nerve  roots,  and  spinal  cord.  In  1876, 
Eichhorst^  reported  a  case  of  the  disease  under  the  name  of 
"acute  progressive  neuritis,"  and  at  the  autopsy  he  found  the 
peripheral  nerves  degenerated,  while  the  brain  and  spinal  cord 
were  normal.  Both  Eisenlohr^  and  Joffroy*  reported  cases  of  the 
affection  in  1879,  and  in  the  following  year  two  important 
contributions  from  the  pen  of  Leyden^  appeared  on  the  subject. 
In  1881,  Grainger  Stewart^  reported  three  examples  of  the 
disease,  in  one  of  which  Hamilton,  who  conducted  the  post- 
mortem examination,  found  the  nerves  diseased,  and  the  brain 
and  spinal  cord  nearly  healthy.  The  morbid  changes  which 
have  been  found  in  the  nerves  consist  of  complete  destruction 
of  many  of  the  nerve  fibres,  and  partial  destruction  of  others. 
The  perineurium  of  the  individual  bundles  has  also  been 
found  thickened,  and  Leyden  has  observed  an  accumulation 
of  fat  cells  between  the  bundles,  which,  in  some  cases,  was  so 
great  that  the  nerve  was  distinctly  enlarged  at  the  point  affected. 
He  likewise  observed  a  deposit  of  pigment  around  the  blood- 

'  Dum^niL     Gazette  Hebdom.,  1864,  p.  203;  and  Ihid.,  1866,  pp.  51,  67,  84. 
■      '^  Eichhorst.     "  Neuritis  acuta  progressiva."    Virchow's  Archiv. ,  Bd.  LXIX. 

^  Eisenlohr.  "  Idiopathische  subacute  Muskellahmung  und  Atrophic."  Cen- 
tralbl.  f.  Nervenheilkund,  1879.  Abstr.  Centralbl.  fiirMed.  Wissensch.  Bd.  XVII., 
1879,  p.  880. 

*  Joffroy.  "  NSvrite  parenchvmateuse,  spontan^e,  gea^ralisee  on  partielle." 
Arch,  de  physiol..  Tome  VI.,  1879,  p.  J  72. 

"  Leyden.  Charit^-Annalen,  Bd.  V.  (Jahrgang,  1878),  Berl.,  1880,  p.  206 ;  and 
Zeitschrift  fiir  klin,  Med.,  1880. 

"  Stewart  (Grainger).  "  On  paralysis  of  hands  and  feet  from  disease  of  nerves." 
Eeprint  from  Edinburgh  Medical  Journal,  April,  1881. 


THE  PERIPHERAL   NERVES.  355 

vessels,  not  only  at  the  most  altered  parts  of  the  nerve,  but  also 
extending  downwards  into  the  small  intra-muscular  nerve 
bundles.  Leyden  regards  this  pigment  as  an  evidence  of  a 
hemorrhagic  inflammation  of  the  tissue  between  the  nerve  fibres, 
and  he  believes  that  the  absence  of  any  sign  of  multiplication  of 
nuclei  proves  that  the  nerve  fibres  had  become  atrophied 
through  the  compression  caused  by  the  congestion  of  the  tissues 
surrounding  them. 

(4)  Segynental  Periaxillary  Neuritis. — By  inducing  chronic 
lead  poisoning  in  guinea-pigs  Gombault^  has  produced  morbid 
changes  in  the  peripheral  nerves,  which  he  has  described  under 
the  name  of  "  ndvrite  segmentaire  peri-axile."  The  lesion  con- 
sists of  a  parenchymatous  neuritis,  but  the  whole  length  of  a 
fibre  is  not  implicated.  A  segment  lying  between  two  of  the 
nodes  of  Ranvier  is  diseased  while  those  on  each  side  of  it  remain 
healthy,  although  several  segments  may  be  affected  in  the  course 
of  one  fibre.  The  medullary  sheath  and  the  protoplasm  of  the 
fibre  are  at  first  alone  implicated  in  the  morbid  change,  while 
the  axis  cylinder  remains  for  a  long  time  uninterrupted.  After 
a  time  the  diseased  segment  may  either  be  restored  by  the 
growth  of  a  new  medullary  sheath,  or  the  axis  cylinder  becomes 
ruptured,  and  the  peripheral  end  of  the  fibre  then  undergoes 
the  Wallerian  degeneration.  Gombault  has  met  with  this  form 
of  neuritis  in  man.  He  observed  it,  for  example,  in  a  case  of 
traumatic  neuritis,  and  in  the  anterior  roots  of  the  cervical 
nerves  in  a  case  of  amyotrophic  lateral  sclerosis. 

§  192.  Diagnosis. 

When  pain  and  parassthesige  in  the  area  of  distribution  of  a 
certain  nerve  are  accompanied  at  first  by  symptoms  of  sensory 
and  motor  irritation,  and  soon  followed  by  anaesthesia  and  motor 
paralysis,  and  when  at  the  same  time  painful  swelling  of  the 
nerve  can  be  detected,  there  can  be  no  doubt  that  neuritis  is 
present.  Chronic  neuritis  may  easily  be  mistaken  for  neuralgia  ; 
and,  indeed,  the  distinction  between  the  two  is  by  no  means  clear 
at  any  time.  If  the  pain  be  continuous  and  the  affected  nerve 
tender  over  a  large  portion  of  its  track,  and  not  simply  over  the 

'  Gombault.  N^vrite  segmentaire  p€ri-axile.  Arch,  de  Neurologic,  Tome  I, 
1880-81,  pp.  11  and  178. 


356  GENEEAL  DISEASES  OF 

points  of  Yalleix,  and  if  anaesthesia  and  paralysis  occur  at  an 
early  period,  the  case  is  most  probably  a  neuritis.  Neuritis  is 
readily  distinguished  from  muscular  rheumatism  by  the  seat 
and  extent  of  the  pain,  whilst  no  pain  is  felt  as  in  the  latter 
affection  during  contraction  of  the  affected  muscles,  or  when 
pressure  is  made  over  them. 

Thrombosis  and  evibolism  of  the  larger  vessels  of  the  extre- 
mities may  be  recognised  by  the  coincident  disturbances  of  the 
circulation,  and  by  the  oedema  and  other  symptoms. 

The  diagnosis  of  neuritis  and  the  central  diseases  of  the  ner- 
vous system  will  be  .subsequently  described.  It  will  suface  to 
state  at  present  that  the  central  diseases  most  likely  to  be 
mistaken  for  neuritis  are  those  in  which  the  posterior  roots  of 
the  nerves  are  maintained  in  a  state  of  irritation,  such  as 
the  neuralgic  form  of  locomotor  ataxia,  the  various  forms  of 
spinal  meningitis,  and  compression  myelitis.  The  affections  most 
likely  to  be  mistaken  for  progressive  multiple  neuritis  are  acute 
ascending  paralysis,  and  the  subacute  general  spinal  paralysis  of 
Duchenne.  It  is  indeed  somewhat  doubtful  whether  acute 
ascending  paralysis  may  not  be  an  acute  form  of  progressive 
multiple  neuritis,  and  it  is  certain  that  cases  of  neuritis  have 
been  described  under  the  name  of  acute  ascending  paralysis.  We 
shall  still,  however,  describe  acute  ascending  paralysis  as  a  sepa- 
rate affection,  and  shall  give  it  a  place  amongst  spinal  diseases, 
and  consequently  the  symptoms  which  serve  to  distinguish 
between  it  and  multiple  neuritis  will  then  be  mentioned. 

§  193.  Prognosis. 
The  prognosis  is  always  doubtful,  both  on  account  of  the  long 
duration  of  the  disease,  the  secondary  paralytic  and  trophic 
symptoms  which  supervene,  and  the  possible  transference  of  the 
morbid  processes  to  the  central  nervous  system.  The  prognosis 
of  the  acute  traumatic  form  is  relatively  favourable,  and  the 
same  may  be  said  of  the  subacute  and  chronic  forms,  which  result 
from  injury  of  the  nerves.  Idiopathic  and  rheumatic  forms  are 
frequently  very  obstinate  and  tedious,  and  only  the  slight  cases 
are  likely  to  terminate  favourably.  The  prognosis  must  depend 
in  every  case  on  the  causes  and  extent  of  the  lesion,  and 
especially  upon  the  individual  peculiarities  which  may  be  present. 


THE  PERIPHERAL   NERVES.  357 

Our  knowledge  of  progressive  multiple  neuritis  is  too  limited  to 
enable  us  to  foretell  its  course  with  certainty,  but  it  is  at  least 
known  that  a  considerable  proportion  of  cases  recover,  either 
partially  or  wholly. 

§  194.  Treatment 

The  treatment  must  first  be  directed  to  the  removal  of  the 
cause,  and  surgical  interference  is  frequently  necessary  in  cases 
of  injury.  At  other  times  the  treatment  must  be  directed 
against  articular  rheumatism,  inflammation  of  tendons,  syphilis, 
and  other  morbid  conditions. 

In  simple  congestion  the  steady  application  of  ice  along  the 
track  of  the  affected  nerve,  elevation  of  the  part,  and  absolute 
rest  suffice  to  arrest  the  disease. 

If  acute  neuritis  is  established,  energetic  antiphlogistic  treat- 
ment must  be  adopted,  consisting  of  local  depletion,  application 
of  ice,  purgatives,  favourable  position  of  the  parts,  and  absolute 
rest.  Large  doses  of  quinine  may  be  useful,  and  the  subcutaneous 
injection  of  morphia  and  atropia  is  necessary  to  allay  pain. 

In  the  subacute  and  chronic  forms  the  use  of  the  antiphlogistic 
treatment  must  be  less  active.  Cold  may  be  applied  at  first,  but 
in  the  later  stages  of  the  affection  counter  irritation,  by  means  of 
the  faradic  brush,  painting  Avith  iodine,  or  blistering,  is  more 
likely  to  prove  useful.  In  obstinate  and  chronic  cases,  recourse 
may  be  had  to  energetic  counter  irritants,  such  as  the  moxa  and 
actual  cautery.  Hot  baths,  such  as  those  of  Wilbad,  Gastein, 
Teplitz,  Wiesbaden,  mud,  and  strong  saline  baths  have  also  been 
found  useful  in  the  treatment  of  neuritis. 

The  galvanic  current  is,  however,  the  most  efficient  remedy 
for  all  forms  of  chronic  neuritis.  The  best  mode  of  employing 
it  is  to  keep  the  anode  steadily  applied  over  the  affected  spot 
every  day  for  a  few  minutes,  but  other  modes  of  application 
may  be  required  to  meet  the  special  circumstances  of  the  case. 
In  severe  cases  absolute  rest,  assisted  by  an  appropriate  position, 
is  a  necessary  part  of  the  treatment,  and  the  patient  should  be 
warned  against  taking  active  exercise,  or  exposing  himself  to 
cold  and  wet. 

Progressive  multiple  neuritis  must  be  treated  at  first  by  com- 
plete rest  in  bed.     The  drug  treatment  must  vary  according  to 


358  GENERAL  DISEASES   OF 

the  constitution  of  the  patient  and  the  complications  which  may 
be  present.  If  the  patient  is  subject  to  rheumatism  salicylate 
of  soda  may  be  given,  and  if  he  is  suffering  from  nephritis  the 
treatment  must  vary  accordingly.  When  the  disease  has  become 
chronic,  electrical  treatment,  massage,  graduated  exercise,  and 
change  of  air  may  be  adopted. 

§195.  Atrophy  of  the  Nerves. 

Atrophy  of  the  nerves  is  generally  observed  as  a  secondary 
affection  of  other  abnormal  conditions,  as  wounds,  compression, 
and  inflammation  of  nerves,  although  there  may  be  a  congenital 
atrophy  or  deficiency  of  the  peripheral  nerves,  whilst  primary  or 
idiopathic  atrophy  of  them  does  occasionally  occur. 

Congenital  Defects  of  Nerves. — The  nerves  are  defective  or 
"absent,  when  portions  of  the  body  are  incompletely  formed. 
When  the  nose  is  arrested  in  its  development,  the  olfactory  nerve 
is  wanting.  When  no  eyes  have  been  formed,  not  only  are  the 
optic  nerves  absent,  but  the  third,  fourth,  and  sixth  pairs  are  also 
deficient.  In  a  cyclops,  in  which  the  face  was  almost  entirely 
wanting,  no  facial  nerve  could  be  found,  and  when  the  tongue  is 
wanting  the  lingual  branches  of  the  fifth  and  the  hypoglossal 
nerves  are  absent.  In  monsters,  in  which  one  or  more  of  the 
extremities  is  imperfect,  there  is  a  corresponding  deficiency  of 
the  nerves  of  that  limb.^ 

In  Idiopathic  Atrophy  the  nerve  is  diminished  in  size  and  has 
a  grey  semi-transparent  aspect,  there  is  a  moderate  hypertrophy 
of  connective  tissue,  and  simple  disappearance  of  the  nerve  fibrils 
without  fatty  degeneration  of  the  medulla. 

Secondary  Atrophy. — The  histological  changes  which  accom- 
pany secondary  atrophy  of  the  nerves  have  already  been  described 
in  the  chapter  on  the  Trophoneuroses.  The  atrophied  nerve 
appears  to  the  naked  eye  as  a  pale  grey,  translucent,  slender, 
flattened  band ;  its  sheath  is  sometimes  flaccid,  but  more  fre- 
quently it  is  thickened  from  hypertrophy  of  the  connective  tissue, 
and  coalesced  with  the  surrounding  tissues. 

Secondary  atrophy  of  the  nerves  is  observed  in  progressive 
muscular   atrophy,    bulbar   paralysis,  many  forms   of  myelitis, 

'  Rokitansky  (Carl).  A  manual  of  pathological  anatomy.  Syd.  Soc,  Vol.  III., 
Lond.,1850,  p.  455. 


THE   PERIPHERAL   NERVES.  359 

infantile  paralysis  and  the  corresponding  paralysis  of  adults, 
section  or  compression  of  nerves,  and  neuritis.  Destruction  or 
abolition  of  the  functions  of  peripheral  organs  causes  an  atrophy 
which  extends  in  a  centripetal  direction,  the  best  known  form 
being  atrophy  of  the  optic  nerve  after  extirpation  of  the  globe  of 
the  eye.  A  centripetally  progressive  atrophy  of  the  divided 
nerves  has  been  observed  after  amputation  of  an  extremity;  it 
usually  appears  as  a  simple  attenuation  of  the  nerves,  and 
extends  to  the  grey  substance  of  the  spinal  cord  in  which  it 
induces  secondary  changes. 

Symptoms. — Idiopathic  atrophy  of  the  optic  nerve  is  the  only 
form  of  which  we  possess  any  knowledge,  and  secondary  atrophy 
is  only  a  result  of  some  other  disease.  It  may  be  laid  down  .as  a 
general  law  that  wherever  atrophy  is  developed  the  function  of 
the  nerve  is  lowered  or  lost.  Atrophy  of  nerves  may  be  recognised 
by  electrical  examination,  and  in  the  case  of  the  optic  nerve  by 
the  ophthalmoscope.  When  the  faradic  and  galvanic  irritability 
are  much  below  the  normal,  or  altogether  lost  in  cases  where  the 
muscles  are  not  completely  atrophied,  it  may  be  inferred  that  a 
condition  of  degeneration  and  atrophy  of  the  nerve  supplying 
them  exists. 

The  prognosis  varies  with  the  nature  of  the  primary  disease. 
If  recovery  from  the  conditions  causing  the  atrophy  be  possible, 
then  the  function  of  the  nerve  may  be  restored ;  but  if  that  be 
impossible,  or  if  the  atrophy  has  persisted  for  a  long  period  the 
prognosis  is  unfavourable. 

Treatment — The  treatment  depends  essentially  upon  the 
primary  disease,  and  when  this  can  be  removed  recovery  from 
the  atrophy  may  be  expected.  Electricity  is  the  best  remedy  in 
the  treatment  of  the  atrophy  itself,  and  the  galvanic  current  is 
by  far  the  best  method  of  employing  it.  Even  atrophy  of  the 
optic  nerve  appears  to  have  been  much  benefited  by  the  use  of 
the  galvanic  current.  In  the  paralyses  which  accompany  atrophy 
of  a  nerve,  energetic  shampooing  of  the  limbs,  warm  baths,  saline 
baths,  alternate  warm  and  cold  douches,  friction,  either  alone  or 
with  spirituous  and  stimulating  liniments,  may  be  employed. 


860  GENERAL  DISEASES   OF 

{IIL)-HYPERTEOPHY  AND  NEOPLASTIC  FORMATIONS   IN  THE 

NERVES. 

§  196.  True  and  False  Neuromata. 

Hypertrophy  of  the  peripheral  nerves  is  so  rare  as  to  be 
regarded  a  mere  curiosity.^  The  hypertrophy,  as  a  rule,  consists 
of  an  increase  of  volume  caused  by  interstitial  growth  of  connec- 
tive tissue.  Occasionally,  however,  there  is  true  hyperplasia  of 
the  nerve  tissue,  consisting  of  an  increase  in  the  number  of 
nerve  fibres  and  in  the  thickness  of  the  medullary  sheath,^  or 
even  of  the  axis  cylinder.*  Remarkable  thickening  and  hyper- 
trophy of  the  nerves  have  been  observed  in  many  instances  of 
elephantiasis,  and  also  in  other  diseases. 

Neoplastic  Formations. — Growths  in  nerves  may  be  subdi- 
vided into  two  classes — true  diad.  false  neuromata.  True  neuro- 
mata consist  wholly  or  chiefly  of  true  nerve  substance  ;  while 
false  neuromata,  although  seated  on  the  nerves  and  proceeding 
from  them,  are  not  composed  of  nerve  tissue. 

§  197.  Pathological  Anatomy. 

True  Neuroma. — This  growth  consists  chiefly  of  nerve  fibres, 
more  or  less  mixed  with  connective  tissue  which  is  sometimes 
soft,  sometimes  tough,  sometimes  vascular,  and  at  other  times 
almost  destitute  of  vessels.  Various  forms  of  neuromata  have 
been  distinguished,  such  as  fibro-neuroma,  glio-neuroma,  myxo- 
neuroma,  neuroma  teleangiectodes,  &c.  It  is  doubtful  whether 
ganglion  cells  have  ever  been  found  in  neuromata. 

Neuromata  occur  most  frequently  in  spinal  nerves,  rarely 
in  sympathetic  nerves,*  and  still  more  rarely  in  one  of  the 
cerebral  nerves.  They  vary  from  the  size  of  a  millet  seed  up  to 
that  of  the  closed  fist.  There  are  two  forms  of  true  neuromata. 
In  one  form  medullated  double  contoured  fibres  are  common,^  and 
they  give  to  the  tumour  a  medullary  white  aspect ;   hence  it 

^  Rokitansky  (Carl).  A  manual  of  pathological  anatomy.  Syd.  Soc,  Vol.  III., 
1850,  p.  457. 

2  Moxon.     Guy's  Hospital  Reports.     Series  III.,  Vol.  VIIL,  1862,  p.  260. 
■''  See  Virchow.    Krankhaften  Geschwiilste.    Bd.  III.,  1867,  p.  265. 

*  Smith  (R. ).  A  Treatise  on  the  pathology,  diagnosis,  and  treatment  of 
Neuroma.     Dublin,  1849.     p.  19. 

*  Heller  (Arnold).    Multiple  Neurome.    Virch.  Arch.,  Bd.  XLIV.,  1868,  p.  338. 


THE   PERIPHERAL  NERVES.  361 

has  been  called  neuroma  rnyelinicwm  by  Vircbow.^  This  form 
is  frequently  met  with  after  amputations.  In  the  other  form, 
extremely  fine  fibres  are  so  blended  as  to  form  a  felt-like  mass 
resembling  fibro-myoma  of  the  uterus ;  the  fibres  are  non- 
medullated,  and  consequently  this  variety  has  been  called,  by 
Virchow,  neiiroma  amyelinicuTii.  It  was  formerly  mistaken  for 
fibroma  or  fibro-sarcoma. 

False  Neuroma. — The  main  portion  of  the  tumour  does  not 
consist  of  nerve  tissue,  and  the  fibres  proceeding  from  the  affected 
nerve  into  the  tumour  do  not  appear  to  be  affected  except  by 
compression.  Various  tumours  belong  to  the  category  of  false 
neuromata. 

(a)  Fibromata. — These  tumours  are  composed  of  connective 
tissue,  enclosing  a  few  nerve  fibres.  They  appear  in  the  form  of 
dense  small  knots,  and  the  majority  of  the  small  tumours  in 
the  nerves  called  tuhercvla  dolorosa  consist  of  fibrous  tissue, 
although  these  small  and  very  painful  tubercles  may  belong  to 
any  of  the  varieties  of  tumours  found  in  nerves. 

(h)  Myxomata. — These  tumours  are  formed  of  mucous  tissue, 
and  they  are  frequently  met  with  in  nerves.  They  consist  of 
soft,  lobulated,  reddish,  transparent,  gelatinous  growths,  and 
the  characteristic  stellate  intercommunicating  cells  are  found 
on  microscopic  examination.  Cystic  formations  are  sometimes 
found  in  the  myxomata,  leading  to  the  formation  of  a  group 
termed  neuroma  cysticwm. 

(c)  Gliomata  have  hitherto  only  been  found  in  the  auditory 
nerve. 

(d)  Sarcomata  of  various  kinds  occur  in  nerves;^  and  transi- 
tional forms  between  fibroma^  and  myxoma*  are  not  unfrequently 
observed. 

(e)  Carcinomata  are  frequently  met  with  and  under  various 
forms.  Scirrhous,  and  medullary  cancer  are  often  observed, 
and  melanoid  cancer  is  also  not  uncommon.      Cancer  is,  as  a 

1  Virchow  (R.).     Krankhaften  Geschwiilste.     1867.     Bd.  III.,  p.  245. 

*  Volkmann.  "  Ueber  ein  faustgrosses  iilcerirtes  Neiirom  ein  Handteller." 
Virchow's  Archiv.,  XII.,  1857,  p.  27. 

^  Hitchcock.  "  Some  remarks  on  Neiiroma,  with  a  brief  Account  of  three  cases 
of  Anomalous  Cutaneous  Tumomrs  in  one  Family."  American  Journal  of  Medical 
Sciences,  1862. 

''Schuh.  "Textur  der  Neurome."  Zeitschrift  der  Gessellsch.  der  Aerzte  zu 
Wien.     Jahrgang,  XIII.,  1857,  p.  12. 


362  GENEEAL    DISEASES   OF 

rule,  secondary  ;  but  occasionally  it  is  primary,  and  it  always 
causes  more  or  less  complete  destruction  and  degeneration  of  the 
nerve  fibres. 

(/)  Syphilitic  Gummata  sometimes  form  in  the  cerebral 
nerves  at  the  base  of  the  cranium,  and  are  generally  propagated 
from  the  membranes  of  the  brain. 

(g)  Lepra  Nervorum  generally  appears  as  a  diffuse,  more  or 
less  fusiform,  swelling  of  the  nerves.  It  consists  of  a  develop- 
ment of  granulation  tissue,  which  is  often  indistinguishable  from 
that  produced  in  inflammation. 

The  size  of  neuromata  is  extremely  variable.  Some  are  not  larger  than 
a  ninstard  seed,  while  others  grow  to  the  size  of  a  man's  head  ;  but  the 
majority  of  them  range  from  between  the  size  of  a  bean  and  that  of  a 
hen's  egg. 

The  number  of  the  tumours  may  also  be  very  variable.  At  times  there 
is  only  a  sohtary  tumour,  while  at  other  times  a  large  number  may  be 
present  either  at  a  circumscribed  spot  or  distributed  over  the  body.  When 
the  tumoiirs  are  locally  numerous  they  may  either  form  a  series  of  knots  in 
the  same  nerve,  or  munerous  knots  in  the  various  branches  of  one  trunk  or 
plexus.  As  many  as  from  five  or  eight  hundred  up  to  several  thousand 
tumours,  distributed  over  all  parts  of  the  body,  but  chiefly  in  the  spinal 
nerves,  have  been  met  with  by  different  observers.^ 

The  relations  of  the  tumours  to  the  nerves  are  variable.  At  times  the 
new  formation  is  on  one  side  of  the  nerve,  so  that  the  latter  seems  to  run 
over  its  surface  ;  at  other  times  it  occupies  the  centre  of  the  nerve  ;  while 
in  still  other  cases  the  nerve  runs  directly  into  the  tumour,  the  fibres 
breaking  up  into  a  kind  of  brush  or  pencil.  In  true  neuromata  either  the 
whole  or  a  portion  of  the  fibres  of  the  nerve  participate  in  the  new  forma- 
tion ;  false  neuromata  proceed  for  the  most  part  from  the  neurilemma,  and 
the  nerve  fibres  may  remain  more  or  less  intact,  or  they  may  be  com- 
pressed and  completely  destroyed. 

§  198.  Etiology. — Some  individuals  appear  to  have  a  certain 
predisposition  towards  the  formation  of  neuromata,  and  phthisical 
and  scrofulous  persons  seem  to  be  specially  liable  to  their  forma- 
tion. Isolated  neuromata  are  more  common  in  women,  while 
multiple  neuromata  occur  almost  exclusively  in  men.  They 
occur  at  all  ages,  and  are  often  congenital. 

The  best  known  of  the  direct  causes  are  blows,  pressure, 
penetration  and  retention  of  foreign  bodies,  and  various  other 

1  Virchow.  Krankhaften  Geschwulste.  Vol.  III.,  1867,  p.  293.  See  also  Smith 
(R.).    Op.  cit.  (case  of  Michael  Lawlor),  p.  17. 


THE   PERIPHERAL   NERVES.  363 

injuries.  Neuromata  are  also  frequently  found  in  the  cicatrices 
formed  after  nerves  have  been  divided  or  injured,  and  rounded 
and  elongated  swellings  of  the  nerves  are  often  met  with  in 
the  cicatrices  of  stumps  after  amputation. 

Chronic  neuritis  may  also  be  the  starting  point  of  neuromata, 
and  syphilis,  lepra,  and  elephantiasis  may  lead  to  the  formation 
of  tumours  in  nerves,  but  in  a  large  number  of  cases  no  definite 
cause  can  be  traced. 

§  199.  Symptoms. — The  symptoms  of  neuromata  are  variable. 
Many  tumours  cause  no  symptoms  throughout,  while  others 
occasion  intense  and  persistent  suffering.  Isolated  neuromata 
generally  give  rise  to  severe  and  incurable  neuralgia,  hence  they 
have  been  called  tubercida  dolorosa.  The  pain  may  be  tearing, 
lancinating,  aching,  boring,  or  burning;  it  is  almost  always 
remittent,  or  completely  intermittent ;  but  when  the  paroxysm 
comes  on,  the  pain  gradually  increases  in  intensity,  and  radiates 
from  certain  points  towards  the  periphery.  The  pain  is  increased 
by  cold  and  damp  weather,  by  pressure,  or  the  slightest  move- 
ment of  the  affected  limb ;  and  in  women,  frequently  by  the 
return  of  the  menses,  or  by  pregnancy.  It  may  often  be  made 
to  disappear  temporarily  by  firm  pressure  on  the  nerve  above 
the  tumour.  The  pain  is  generally  more  severe  in  small 
tumours  seated  on  peripheral  cutaneous  branches  than  in  larger 
tumours  of  deeper  seated  nerve  trunks.  In  addition  to  pain,  a 
feeling  of  numbness  and  formication,  and  a  sensation  of  heat  or 
cold  are  often  felt  in  the  area  of  distribution  of  the  affected 
nerve. 

Motor  disturbances  are  rare,  but  sometimes  occur  in  the  form 
of  tremors,  spasms,  and  contractures,  and  these  may  ultimately 
give  place  to  complete  paralysis.  Anaesthesia  may  also  be 
present  in  various  degrees,  and  not  unfrequently  appears  in  the 
form  of  ancesthesia  dolorosa,  especially  in  cancer.  In  very  ex- 
citable persons  diffused  pain  may  occur  in  the  head  and  spine ; 
and  occasionally  epileptoid  or  tetanoid  convulsions  supervene 
during  the  paroxysms  of  pain. 

The  further  course  of  the  disease  varies  in  different  instances. 
The  symptoms  may  become  so  intense  that  the  patient  experi- 
ences the  most  frightful  suffering,  whilst  constant  sleeplessness 


364         GENERAL  DISEASES  OF  THE  PERIPHERAL  NERVES. 

and  secondary  disturbances  may  lead  to  a  high  degree  of  cachexia, 
exhaustion,  and  even  death. 

The  symptoms  sometimes  remit  and  ultimately  cease,  and  in  a 
few  cases  the  tumour  disappears.  In  other  cases  paralysis  super- 
venes, and  tumour  of  the  cauda  equina  causes  anaesthesia  of  the 
lower  extremities  of  variable  distribution,  paraplegia,  and  various 
trophic  disturbances. 

True  neuromata  may  remain  stationary  for  many  years  with- 
out producing  any  deleterious  effect,  while  multiple  neuromata 
often  cause  few  or  no  symptoms,  and  are  sometimes  only  dis- 
covered accidentally  during  life  or  at  the  autopsy;  at  other  times 
they  occasion  various  disturbances  by  their  mechanical  action, 
and  when  the  sympathetic  nerves  are  implicated  they  may  induce 
general  debility,  anaemia,  and  many  other  anomalous  symptoms. 

The  diagnosis  of  neuromata  is  founded  almost  exclusively  on 
the  presence,  on  certain  nerves,  of  round  or  oval  tumours,  of 
variable  size,  which  are  movable  latterly,  but  not  in  the  direction 
of  the  length  of  the  nerves. 

Prognosis. — True  neuroma  is  always  a  local  and  benign  affec- 
tion, but  it  may  occasionally  return  once  or  several  times  after 
extirpation.  The  prognosis  of  spurious  neuromata  depends  upon 
the  nature  of  the  tumour,  but  it  is  always  unfavourable  when 
the  affection  is  accompanied  by  severe  neuralgic  pains,  and  serious 
trophic  and  vaso -motor  disturbances,  and  when  extirpation  is  im- 
practicable. 

§  200.  Treatment. — The  only  successful  treatment  of  neuro- 
mata is  afforded  by  the  extirpation  or  destruction  of  the  tumour. 
Extirpation  succeeds  best  when  the  growth  can  be  removed 
whilst  the  nerve  is  left  intact.  When  extirpation  is  impossible, 
destruction  of  the  tumour  may  be  undertaken  by  caustics  or 
electrolysis,  but  neither  of  these  methods  is  very  successful. 
When  the  tumour  cannot  be  removed,  palliative  treatment  to 
alleviate  the  sufferings  of  the  patient  must  be  adopted. 


365 


CHAPTER   III. 


DISEASES   OF   THE   NEEVES   OF   SPECIAL   SENSE. 

I.)-DISEASES  OF  THE  OLFACTORY  NERVE. 

The  sense  of  smell  is  excited  by  the  contact  of  odoriferous  par- 
ticles with  the  mucous  membrane  of  the  nose,  or  rather  with  that 
part  of  it  to  which  the  olfactory  nerves  are  distributed.  Two 
delicate  scroll-like  bones,  called  turbinated  bones,  are  attached 
to  the  lateral  walls  of  each  nasal  cavity,  and  divide  the  latter  into 
three  chambers,  the  one  being  above  the  other.  The  uppermost 
two  of  these  constitute  the  true  olfactory  chambers,  whilst  the 
lowest  passage  is  merely  used  for  respiratory  purposes.  Peculiar 
rod-shaped  cells,  described  by  Max  Schultze,  which  are  attached 
to  the  ramifications  of  the  olfactory  nerves  in  the  mucous 
membrane  of  the  nose,  appear  to  be  the  peripheral  end-organs 
of  smell. 

When  odoriferous  particles  are  present  in  the  inspired  air  passing 
through  the  lower  nasal  chambers,  they  diifuse  into  the  upper  chambers, 
and,  on  coming  in  contact  with  the  olfactory  epithelium,  originate  the 
impulses  which  cause  the  sensation  of  smell.  The  smell  induced  by  simple 
diffusion  of  odoriferous  particles  is,  however,  l^sually  very  imperfect,  but 
a  more  complete  contact  of  those  particles  with  the  olfactory  mucous 
membrane  is  obtained  by  the  forcible  nasal  inspiration  called  snijinff.  The 
mucous  membrane  of  the  nose  is  endowed,  in  addition  to  the  speciiic  olfac- 
tory sense,  with  the  power  of  appreciating  sensations  related  to  those  of 
cutaneous  sensibility,  and  which  are  caused  by  pungent  gases  and  volatile 
substances,  such  as  ammonia,  mustard,  and  acetic  acid.  Sensations  of  smell 
are  conveyed  by  the  olfactory  nerves,  and  pungent  sensations  by  the  branches 
of  the  fifth  nerves  which  are  distributed  to  the  nasal  mucous  membrane. 

§  201.  Methods  of  Testing  the  Sense  of  Smell. 

Various  substances  may  be  used  to  test  the  sense  of  smell,  but 
care  should  be  taken  not  to  employ  those  having  a  pungent  odour,  in 
order  to   avoid  irritation  of  the  fifth  nerve.     The  best  substances  are 


366  DISEASES   OF   THE 

volatile  oils,  as  the  oils  of  bergamont,  lavender,  cajeput,  or  cloves,  and 
the  fetid  gum  resins,  and  other  substances  having  a  penetrating  odoiu',  as 
camphor,  turpentine,  and  musk. 

It  must  be  remembered  that  our  perception  of  delicate  flavours  is  due, 
not  to  the  sense  of  taste,  but  of  smell ;  hence,  in  testing  the  latter,  it  is 
necessary  to  employ  solids  and  fluids  which  possess  a  delicate  aroma,  or 
bouquet,  such  as  roast  beef,  cheese,  or  wine. 

The  sense  of  smell  responds  only  very  feebly  to  electrical  stimuh,  and 
consequently  the  galvanic  cm-rent  cannot  be  employed  as  a  test  for  it.  In  a 
case  of  bilateral  anaesthesia  of  the  fifth  pair  of  nerves  and  in  which  con- 
sequently strong  currents  could  be  used.  Dr.  Althaus  found  that  galvanic 
stimulation  of  the  mucous  membrane  of  the  nose  gave  rise  to  the  sensation 
of  the  smell  of  phosphorous. 

§  202.  Hyperosmia,  or  Olfactory  Hypercesthesia,  occurs  fre- 
quently in  diseases  of  the  central  nervous  system.  Hysterical 
patients  are  often  possessed  of  an  abnormally  acute  olfactory 
sense,  so  that  they  discriminate  smells  which  are  quite  inappre- 
ciable to  others,  and  distinguish  various  substances  and  even 
persons  by  the  sense  of  smell  alone. 

The  acuteness  of  the  sense  of  smell  may,  like  that  of  the  other 
senses,  be  greatly  increased  by  education.  A  boy,  James  Mitchell, 
who  was  born  blind,  deaf,  and  dumb,  successfully  employed  the 
sense  of  smell  like  a  domestic  dog  in  distinguishing  persons  and 
things.^  Certain  substances,  as  strychnine,  either  taken  inter- 
nally or  applied  locally,  have  the  power  of  increasing  for  a  time 
the  sense  of  smell. 

§  203.  Hyperalgesia  of  the  sense  of  smell  is  frequently  ob- 
served in  many  diseases.  Hysterical  patients  often  manifest  a 
decided  aversion  to  fragrant  flowers,  which  are  very  agreeable 
to  most  people ;  while,  on  the  other  hand,  they  frequently  show 
an  equally  unaccountable  predilection  for  odours,  like  that  of 
assafoetida,  which  are  thoroughly  disagreeable  to  others. 

Illusions  or  hallucinations  of  smell,  generally  of  a  repugnant 
nature,  are  often  complained  of  by  the  insane,  these  being 
specially  frequent  in  the  early  stage  of  general  paralysis.  "  The 
insane,"    says  Dr.   Winslow,^  "  in   the    incipient  stage   of   this 

1  M'Kendrick.  Outlines  of  physiology  in  its  relations  to  man.  Glasgow,  1878. 
p.  552. 

'^  Winslow  (Forbes).  On  obscure  diseases  of  the  brain  and  disorders  of  the  mind. 
Lond.,  1860.     p.  598. 


NERVES   OF   SPECIAL   SENSE.  367 

malady,  are  often  heard  to  complain  of  being  exposed  to  the  in 
fluence  of  most  offensive  and  noxious  smells,"  and  he  believes 
that  a  perversion  of  the  sense  of  smell  is  generally  observed  in 
affections  of  the  brain  associated  with  derangement  of  the  diges- 
tive organs.  The  predominant  odours  complained  of  by  the  in- 
sane are  those  of  sulphur  and  putrid  substances,  and  such  patients 
are  often  led  to  believe  that  they  are  surrounded  by  dead  and 
decaying  bodies.  A  bad  smell,  probably  caused  by  irritation  of 
a  limited  portion  of  the  cortex  of  the  brain,  sometimes  con- 
stitutes the  aura  of  epileptic,  and  epileptiform  seizures,^  and 
is  at  other  times  a  symptom  of  an  intracranial  tumour.^  The 
perception  of  a  smell  of  phosphorous  has  been  observed  by 
Althaus^  as  a  symptom  in  a  case  of  supposed  neuritis  of  the 
olfactory  nerve,  and  he  also  proved  that  on  galvanic  excitation  of 
the  olfactory  nerve  the  subject  perceives  a  smell  of  phosphorous. 
Illusions  of  smell  sometimes  occur  after  the  use  of  large  doses  of 
santonins. 

§  204.  Anosmia,  or  Olfactory  Ancesthesia,  consists  of  dimi- 
nution or  complete  abolition  of  the  sense  of  smell.  When  both 
sides  are  affected,  the  sense  of  taste  is  also  considerably  impaired. 
In  anosmia,  indeed,  the  impairment  of  the  sense  of  taste  appears 
more  marked  to  the  patient  than  in  true  gustatory  ansesthesia, 
since  the  enjoyment  derived  from  eating  depends  so  much  upon 
the  perception  of  odorous  substances  and  flavours. 

The  sense  of  smell  is  diminished  in  paralysis  of  both  the 
trigeminal  and  facial  nerves.  When  the  superior  maxillary  divi- 
sion of  the  trigeminus,  which  furnishes  filaments  to  the  nasal 
and  palatine  mucous  membrane,  is  cut  in  animals,  the  mucus  in 
the  nostrils  becomes  thick  and  sanguineous ;  ulcerative  changes 
may  occur  in  the  membrane ;  and  the  sense  of  smell  is  soon  lost. 
Similar  changes  result  from  disease  of  these  nerves  in  man,  and 


'  Jackson  (Hughlings).  "  Clinical  remarks  on  the  occasional  occurrence  of  sub- 
jective sensations  of  smell  in  patients  who  are  liable  to  epileptiform  seizures,  or  who 
have  symptoms  of  mental  derangement,  and  in  others."  The  Lancet,  Vol.  L, 
1866,  p.  659. 

_^  Sander  (W,).  "  Epileptische  Anfalle  mit  subjectiven  Geruchs-Empfindungen 
bei  Zerstorung  des  linken  tractus  olfactorius  durch  einen  Tumor,"  Arch.  f. 
Psychiat.,  Bd.  IV.,  1874,  p.  234. 

^  Althaus  (J.).  The  American  Journal  of  Medical  Sciences,  Vol.  LXXVIL, 
Philad.,  1879,  p.  369. 


368  DISEASES   OF  THE 

lead  to  impairment  of  the  sense  of  smell.  The  first  effect  of 
paralysis  of  the  trigeminus  is  to  render  the  nasal  mucous  mem- 
brane abnormally  dry,  and  this  of  itself  diminishes  the  sense  of 
smell  by  preventing  odorous  particles  from  coming  in  contact 
with  the  peripheral  olfactory  end-organs.  In  facial  paralysis,  on 
the  other  hand,  the  dilators  of  the  alse  nasi  are  paralysed,  so  that 
the  act  of  sniffing  becomes  impossible,  and  odoriferous  particles 
are  prevented  from  coming  into  forcible  contact  with  the  mucous 
membrane  of  the  olfactory  chambers. 

Anosmia  may,  indeed,  be  produced  by  anything  which  pre- 
vents or  retards  the  entrance  of  air  into  the  olfactory  chambers, 
and  consequently  loss  of  smell  is  caused  by  constriction  of  the 
nostrils,  nasal  polypi,  and  occlusion  of  the  nasal  and  pharyngeal 
cavities.  Closure  of  the  nostrils,  however,  leaves  the  perception 
of  flavours  unimpaired,  since  the  aromatic  particles  will  ascend 
from  the  pharynx  through  the  posterior  nares  to  the  olfactory 
chambers.  Oojie  relates  a  case  in  which  both  the  sensations  of 
smell  and  flavour  were  lost  in  consequence  of  adhesion  of  the 
soft  palate  to  the  posterior  wall  of  the  pharynx,  but  these 
sensations  were  restored  when  a  communication  was  established 
between  the  pharynx  and  olfactory  chambers  by  means  of  an 
operation. 

Anosmia  is  sometimes  a  sequel  of  acute  or  chronic  inflamma- 
tion of  the  mucous  membrane  of  the  nose,  and  always  accom- 
panies strumous  and  syphilitic  ozena.  The  sense  of  smell  is 
frequently  blunted  in  old  age,  and  loss  of  smell  is  occasionally 
observed  as  an  early  and  persistent  symptom  of  locomotor  ataxia. 
Loss  of  smell  results  so  frequently  from  injuries  of  the  head  that 
the  affection  has  been  described  under  the  name  of  traumatic 
anosmia.  The  most  frequent  injury  to  cause  anosmia,  in  the 
absence  of  fracture  of  the  cranium,  is  a  blow  or  fall  on  the  occiput, 
and  a  blow  on  the  forehead  is  also  sometimes  followed  by  loss  of 
smell.  A  gentleman  consulted  me  a  short  time  ago  for  what  he 
imagined  to  be  loss  of  taste  and  smell,  caused  by  a  blq.w  on 
the  forehead.  On  testing  the  sense  of  taste,  I  found  that  he 
readily  appreciated  saline,  sweet,  and  bitter  substances,  and  on 
pointing  out  this  to  him  he  significantly  said,  "Yes,  but  my  food  is 
tasteless.  I  do  not  taste  soup  or  roast  beef"  The  loss  of  smell 
was  complete.    Anosmia  of  the  left  nasal  cavity  is  sometimes  asso- 


NERVES  OF  SPECIAL  SENSE.  369 

ciated  with  right  hemiplegia  and  aphasia,  the  result  of  embolism  of 
the  left  middle  cerebral  artery.^  In  other  cases  left-sided  anosmia 
is  associated  with  aphasia  in  the  absence  of  any  paralysis,  and  in 
some  of  these  cases  at  least  the  aphasia  is  of  the  amnesic 
variety.^  In  cerebral  hemiansesthesia,  whether  of  hysterical 
origin  or  caused  by  organic  disease,  the  loss  of  smell  is  on  the 
same  side  as  the  other  sensory  disorders,  and  therefore  pre- 
sumably on  the  opposite  side  to  the  lesion.  Loss  of  smell  is 
sometimes  caused  by  tumours  in  the  anterior  fossa  of  the  skull, 
or  in  one  of  the  anterior  cerebral  lobes,  and  by  basal  meningitis, 
exostoses,  or  caries  of  the  bones ;  it  is  at  other  times  a  con- 
genital affection,  and  then  usually  results  from  absence  of  the 
olfactory  bulbs. 

Morbid  Anatomy  and  Physiology. — Diminution  or  loss  of 
the  sense  of  smell  may  be  caused  by  disease  of  the  peripheral 
end-organs,  of  the  olfactory  nerves,  of  the  conducting  apparatus 
through  the  olfactory  bulbs  and  hemispheres  of  the  brain,  or  of 
the  cortical  centres  themselves.  Loss  of  smell  is  sometimes  due, 
as  we  have  seen,  to  disease  of  the  accessory  olfactory  mechanism. 
As  examples  of  anosmia  from  such  a  cause  may  be  mentioned 
the  diminution  of  smell  caused  by  paralysis  of  the  muscles 
of  the  nose,  and  that  caused  by  local  disease  of  the  nostrils 
and  mucous  membrane.  It  is  most  likely  that  the  ramifi- 
cations of  the  olfactory  nerves  themselves  become  secondarily 
affected  in  chronic  inflammation  and  other  diseases  of  the 
mucous  membrane.  Loss  of  the  sense  of  smell  may  be  caused 
by  disease  of  the  peripheral  end-organs  of  the  olfactory  nerve 
in  the  absence  of  disease  of  the  mucous  membrane.  The  case 
of  an  entomologist  is  reported  by  Strieker,^  who  lost  smell  from 
having  constantly  to  inhale  sulphuric  aether  while  mounting  his 
specimens,  and  Notta*  mentions  the  case  of  a  military  man 
who,  while  obliged  to  superintend  the  cleaning  of  a  common 
sewer,  was  so  powerfully  affected  by  the  stench  that  he  never 

'  Jackson  (Hughlings).  On  loss  of  speech  associated  with  hemiplegia.  London 
Hospital  Eeports,  VoL  I.,  1864,  p.  443. 

*  Ogle.  Anosmia ;  or  cases  illustrating  the  physiology  and  pathology  of  the 
sense  of  smell.    Med.-Chir.  Transactions,  Vol.  LUL,  1870,  p.  274. 

3  Strieker  (W.).  Verlust  des  Geruchs  in  Folge  local  anasthesia.  Virchow's 
Arch.,  Bd.  XLL,  1868,  p.  290. 

*Notta.  "Recherches  sur  la  perte  de  I'odorat."  Arch.  G^n^r.  de  Me'd.,  Vie 
Serie,  Tome  XV.,  1870,  p.  385. 

VOL.  I.  T 


370  DISEASES   OF  THE 

afterwards  recovered  his  smell.  In  old  people  in  whom  the 
sense  of  smell  is  diminished,  Prdvost^  has  found  the  olfactory 
nerves  thin,  semi-translucent,  and  grey,  and  the  olfactory  bulbs 
much  diminished  in  size ;  a  microscopic  examination  revealed 
atrophy  of  some  of  the  nerve  fibres,  and  complete  destruction  of 
others,  with  a  great  accumulation  of  amyloid  bodies.  The  anosmia 
which  accompanies  locomotor  ataxia  is  most  probably  caused,  as 
has  been  pointed  out  by  Dr.  Althaus  in  several  publications,  by  a 
neuritis  of  the  olfactory  nerves  corresponding  to  the  parenchy- 
matous neuritis  of  the  optic  nerves,  which  is  the  anatomical 
substratum  of  tabetic  amaurosis.  In  one  fatal  case  of  this  kind 
under  his  care,  evidence  of  neuritis  of  the  olfactory  nerves  at  the 
base  of  the  skull  was  found  by  Ferrier,  who  conducted  the  post- 
mortem examination ;  but  the  death  of  the  late  lamented  Lock- 
hart  Clarke,  to  whom  the  specimen  had  been  entrusted,  prevented 
a  microscopic  examination  being  made.^  The  anosmia  which 
accompanies  those  cases  of  cerebral  tumour  which  compress  the 
olfactory  nerves  and  bulbs  is  easily  accounted  for.  Traumatic 
amaurosis  is,  as  we  have  seen,  generally  caused  by  blows  on  the 
occiput.  The  elastic  bones  of  the  cranium  yield  to  some  extent 
to  the  blow,  the  whole  of  the  encephalon  above  the  tentorium  is 
pushed  forwards,  the  anterior  margins  of  the  temporo- sphenoidal 
lobes  impinge  against  the  great  wings  of  the  sphenoid  bones,  and 
the  olfactory  bulbs  are  apt  to  suffer  damage  at  their  points  of 
junction  with  the  brain  near  the  anterior  perforated  spaces,  or 
some  of  the  olfactory  nerves  may  be  ruptured  in  their  passage 
through  the  cribriform  plate  of  the  ethmoid  bone.^  The  anosmia 
which  accompanies  hysterical  hemianaesthesia,  and  that  which 
results  from  disease  of  the  posterior  part  of  the  internal  capsule, 
is  limited  to  the  same  side  as  the  other  sensory  disorders  ;  it  would 
therefore  appear  that  the  olfactory,  like  other  sensory  conducting 
paths,  cross  so  as  to  reach  the  hemisphere  opposite  to  the  affected 
nostril.  In  the  cases  of  aphasia  and  hemiplegia  which  are  asso- 
ciated with  unilateral  anosmia  it  is  important  to  notice  that  the 

'  Provost.  Atrophic  des  nerfs  olfactifs  fr^quente  chez  les  vieillarda,  &c.  Gaz. 
mM.  de  Paris,  1866,  No.  37. 

''Althaus  (J.).  "Beitrage  zur  Physiologie  and  Pathologic  des  Nervus  Olfac- 
torius."    Arch,  fiir  Psychiatric,  Bd.  XII.,  Bcrl.,  1882,  p.  136. 

'  See  Hilton  (J.).  On  the  influence  of  mechanical  and  physiological  rest  and  the 
diagnostic  value  of  pain.    1843.  p.  25. 


NERVES  OF  SPECIAL  SENSE,  371 

paralysed  limbs  and  affected  nostril  are  on  opposite  sides  of  the 
body.  Such  cases  are  caused  by  embolism  of  the  middle  cerebral 
artery,  and  Dr.  Ogle^  thinks  that  the  loss  of  smell  is  caused,  not 
by  softening  of  the  cortical  centre  of  smell,  but  by  softening  of 
the  external  root  of  the  olfactory  bulb,  which  is  supplied,  along 
with  the  motor  area  of  the  cortex  and  Broca's  convolution,  by 
the  middle  cerebral  artery.  In  the  cases  in  which  anosmia  and 
aphasia  are  associated  in  the  absence  of  hemiplegia  the  aphasia 
is  probably  of  the  amnesic  variety,  and  in  such  cases  the  soften- 
ing of  the  cortex  is  likely  to  be  limited  to  the  angular  gyrus  and 
superior  temporo-sphenoidal  convolution,  or  the  area  of  distribu- 
tion of  the  posterior  branch  of  the  Sylvian  artery.  Congenital 
anosmia  is  generally  caused  by  arrest  of  development  of  the 
olfactory  tracts. 

Prognosis. — The  prognosis  depends  upon  the  cause  of  the 
affection.  Those  cases  which  result  from  serious  organic  disease 
are,  of  course,  incurable.  When  the  loss  of  smell  is  due  to  coryza, 
exposure  to  cold,  or  blows  on  the  occiput,  the  prognosis  is  more 
favourable. 

Treatment. — The  treatment  of  hypersesthesia  of  the  olfactory 
sense  must  depend  upon  the  cause  of  the  affection,  and  it  is  im- 
probable that  direct  treatment  of  the  olfactory  nerve  would  be  of 
any  use.  The  treatment  of  anaesthesia  must  be  chiefly  directed 
to  remove  the  cause  of  the  affection;  Duchenne  obtained  good 
results,  especially  in  hysterical  patients,  from  faradisation  of  the 
nasal  mucous  membrane,  and  Beard  and  Rockwell  also  recommend 
faradisation  and  galvanisation,  applied  partly  outside  the  nose 
and  partly  to  the  mucous  membrane,  by  means  of  an  electrode 
made  in  the  form  of  a  sound. 

(II.)— DISEASES  OF  THE  SENSE   OF  SIGHT. 

§  205,  Structure  of  the  Optic  Nerve. — The  optic  nerve  com- 
mences at  the  chiasma  and  passes  into  the  orbit  through  the 
optic  foramen, 

(1)  The  Sheaths  of  the  Optic  Nerve  consist  of  (a)  an  external  sheath  of 
dense  fibrous  connective  tissue,  similar  in  structure  to,  and  continuous  with 

»  Ogle  (W.).  "  Anosmia  ;  or  cases  illustrating  the  physiology  and  pathology  of 
the  sense  of  smell."    Med.-Chir.  Transactions,  Vol.  LIII.,  1870,  p.  263. 


872 


DISEASES   OF   THE 


the  diira  mater  of  the  brain,  and  named  the  dural  sheath  {Fig.  Zl,l)\  (h)  a- 
middle  sheath,  continuous  with  and  of  the  same  structure  as  the  arach- 
noid— the  arachnoidal  sheath  {Fig.  31,  r);  and  (c)  an  inner  sheet  of  fibrous 
connective  tissue,  being  a  continuation  of  the  pia  mater — the  pial  sheath 
{Fig.  31,  jo).  Between  the  dural  and  arachnoidal  sheaths  is  a  lymph  space 
in  open  communication  with  the  subdiu"al  space  of  the  brain,  and  caUed  the 
subdural  space  of  the  optic  nerve  {Fig.  31,  m).  Between  the  arachnoidal  and 
pial  sheaths  is  another  lymph  space,  which  communicates  with  the  sub- 
arachnoidal space  of  the  brain,  and  is  called  the  subarachnoidal  space  of  the 
optic  nerve  {Fiq.  31,  n).  The  subdural  and  subarachnoidal  spaces  of  the 
optic  nerve  can  be  readily  injected  from  the  corresponding  spaces  of  the 
brain,  but  do  not  commimicate  with  one  another. 

(2)  Substance  of  the  Optic  Nerve. — The  optic  nerve  is  composed  of  a 
large  number  of  bundles  of  nerve  fibres  {Fig.  31,  i  i),  separated  from  one 
another  by  trabeculee  of  fibrous  connective  tissue  {Fig.  31,  k  k),  containing 
numerous  connective  tissue  cells,  and  directly  continuous  with  the  pial 
sheath  of  the  optic  nerve.  This  framework  contains  blood-vessels,  and  it 
forms  a  special  accumulation  around  the  arteria  centralis.     The  bundles 


Fig.  31. 


'JHEITIIUn«iM£raLOII|!U. 


Ji  h. 


z    Ji  r 


Fig.  31  (from  Landoia'  "  Physiologic  ").  Horizontal  Section  through  the  Optic  Nen'e 
at  its  point  of  insertion  in  the  globe,  and  its  passage  through  the  membranes  of  the 
eije.—a.  Internal;  6,  Extemallayers  of  the  retina;  c,  Choroid;  d,  Sclerotic; 
«,  Physiological  cup ;  /,  Central  artery  of  the  retina ;  g,  Point  of  its  bifurcation ; 
h.  Lamina  cribrosa ;  I,  Dural  sheath  ;  m.  Subdural  space ;  n,  Subarachnoidal 
space ;  r.  Arachnoidal  sheath ;  p,  Pial  sheath ;  i  i,  Bundles  of  nerve  fibres ; 
k  k.  Connective  tissue  trabeculse. 


NERVES  OF  SPECIAL  SENSE. 


373 


are  of  variable  size,  and  are  composed  of  mediillated  nerve  fibres  that  do 
not  possess  any  sheath  of  Schwann.  The  medullary  sheath  appears  to 
possess  at  times  more  or  less  regular  varicosities  owing  to  an  accumulation 
of  fluid  between  the  axis  cylinder  and  sheath  (Klein). 

The  nerve  fibres  are  separated  from  one  another  by  a  substance  which 
is  identical  with  the  neuroglia  of  the  spinal  cord.  A  large  lymph  space 
may  be  injected  on  the  inner  surface  of  the  pial  sheath,  which  is  continuous 
with  lymph  spaces  situated  within  the  bundles  of  nerve  fibres  and  the 
trabeculse  of  the  framework,  and  with  minute  lymph  spaces  separating  the 
individual  nerve  fibres.  It  will  thus  be  seen  that  the  structure  of  the  optic 
nerve  is  more  like  that  of  the  white  substance  of  the  brain  and  spinal  cord 
than  that  of  the  peripheral  spinal  nerves. 

Sclerotic  Foramen  and  Optic  Disc. — The  fibres  of  the  optic  nerve,  as  well 
as  its  vessels,  pass  through  an  opening  in  the  posterior  part  of  the  sclerotic 
coat  of  the  eyeball,  called  the  sclerotic  foramen.  This  opening,  however,  is 
by  no  means  as  if  it  were  punched  out,  but  is  divided  into  numerous  small 
openings  by  trabeculse  of  fibrous  connective  tissue  derived  from  the  sclerotic 
coat,  the  whole  constituting  a  sieve-like  layer,  which  has  been  called  the 
lamina  cribrosa. 

Choroidal  Ring. — The  fibres  of  the  optic  nerve  also  pass  through  a 
round  or  oval  opening  in  the  choroid  coat,  which  is  called  the  choroidal 
ring,  and  the  edge  of  which  forms  the  boundary  of  the  optic  disc. 


Fig.  32  (from  Landois'  "  Phyaiologie,"  after  Jaeger).  Point  of  Entrance  of_  the 
Optic  Nerve  with  the  Retinal  Vessels.— A  A,  Optic  papilla;  a.  Sclerotic  ring; 
h.  Choroidal  ring  ;  c,  Arteries  ;  d.  Veins  ;  g,  Point  of  bifurcation  of  the  central 
artery  of  the  retina ;  h,  Point  of  bifurcation  of  the  central  vein ;  L,  Lamina 
cribrosa ;  <,  temporal,  and  n,  nasal  side. 


374  DISEASES   OF  THE 

§  206.  Ophthalmoscopic  Appearances  of  the  Healthy  Fundus 

of  the  Eye. 

(1)  Sclerotic  Ring. — Tlie  choroidal  ring  is  generally  larger  than  the 
corresponding  opening  of  the  sclerotic,  and,  consequently,  a  narrow  rim  of 
sclerotic  commonly  appears  within  the  former,  which  is  called  the  sclerotic 
rincf  {Fig.  32,  a). 

(2)  Physiological  Cup. — The  fibres  of  the  optic  nerve,  immediately  after 
passing  through  the  lamina  cribrosa,  radiate  in  all  directions  to  reach  the 
retina,  and  consequently  they  form  a  central  hollow,  which  has  been  called 
the  physiological  cup  {Fig.  31,  e). 

(3)  Optic  Papilla. — As  the  fibres  of  the  optic  nerve  cm^e  over  the  edge 
of  the  sclerotic  they  rise  shghtly  above  the  level  of  the  retina,  and  the 
termination  of  the  optic  nerve  has,  from  this  slight  prominence,  been  called 
the  optic  papilla  {Fig.  32,  A  A). 

(4)  Jlie  Retinal  Vessels. — The  central  artery  of  the  retina  is,  as  already 
mentioned,  derived  from  the  ophthalmic  artery,  while  the  retinal  veins 
return  the  blood  chiefly  to  the  cavemoiis  siaus ;  ccaisequently  the  intra- 
ocular circulation  has  been  regarded  as  part  of  the  cerebral  circulation. 
The  usual  distribution  of  both  artery  and  vein  is  shown  in  Fig.  32,  g  and  h, 
and  it  is  unnecessary  to  enter  into  a  detailed  description  of  them ;  although, 
it  must  be  remembered  that  the  mode  of  distribution  of  the  vessels  varies 
considerably  within  physiological  limits  in  different  individuals.  The 
minute  vessels  of  the  optic  disc  are  derived,  partly  from  the  posterior  ciHary 
arteries,  and  partly  from  the  central  retinal  artery,  twigs  from  both  of 
which  commonly  unite  in  forming  the  "  circle  of  Haller,"  a  series  of  vessels 
which  surrounds  the  optic  nerve  behind  the  disc. 

FUNCTIONAL   AFFECTIONS   OF   THE   SENSE   OF   SIGHT. 

§  207.  Optic  Hyperoisthesia  consists  of  those  conditions  in 
which  external  objects  are  distinctly  seen  in  an  unusually  dim 
light,  or  in  which  the  acuteness  of  vision  is  very  much  greater 
than  occurs  in  ordinary  sight.  Pathological  conditions,  however, 
usually  give  rise  to  painful  feelings  or  to  complicated  psychical 
reactions  in  connection  with  sight,  and  these  conditions  may  be 
called  optic  hyperalgesioe. 

Other  phenomena  of  vision,  which  may  respectively  be  called  phoiopsia 
and  chromatopsia,  may  be  placed  in  the  category  of  optic  hyperaesthesia. 
These  phenomena  are  also  observed  on  mechanical  and  electrical  irritation 
of  the  optic  nerves.  Direct  irritation  of  the  optic  nerves  gives  rise  to 
sparks,  flames,  luminoiis  balls,  discs,  rings,  and  to  appearances  like  forked 
lightning,  sometimes  simply  coloured,  at  other  times  containing  all  the 
colours  of  the  rainbow.  Illusions  of  sight  often  occur  in  cerebral  affections 
and  in  various  forms  of  insanity,  and  depend  on  central  irritation. 


NERVES  OF  SPECIAL   SENSE.  375 

§  208.  Optic  Ancesthesia  is  characterised  by  diminution  or 
abolition  of  vision.  Ttie  anaesthesia  may  declare  itself  in  the 
central  part  or  by  concentric  diminution  of  the  field  of  vision,  or 
both  conditions  may  be  combined.  Diminution  of  sight  through 
an  affection  of  the  nervous  apparatus  is  called  amblyopia,  while 
abolition  of  sight  is  called  ariiaurosis.  These  conditions  may 
be  caused  by  lesions  either  of  the  retina,  disc,  optic  nerves  and 
tracts,  conduction  apparatus  through  the  corpora  quadrigemina 
and  corona  radiata,  or  optic  centres  in  the  cortex. 

The  forms  of  amblyopia  and  amaurosis,  which  occur  in  the  absence  of 
any  apparent  lesion  of  the  fundus  of  the  eye  on  ophthalmoscopie  examina- 
tion, are  those  which  interest  us  at  present.  The  transitory  or  sometimes 
permanent  amam-osis,  which  comes  on  after  exposure  to  cold,  venereal 
excess,  or  suppression  of  profuse  secretions,  belong  to  this  category;  as 
well  as  the  amblyopia  which  occurs  from  irritation  of  the  sensory  branches 
of  the  trigeminus,  and  which  may  be  cured  by  the  extirpation  of  tumours, 
or  the  removal  of  carious  teeth  or  some  other  source  of  irritation. 
Amblyopia  is  also  sometimes  caused  by  irritation  of  remote  organs, 
and  especially  irritation  of  the  abdominal  organs  caused  by  worms, 
constipation,  gastric  affections,  tumoiu-s,  pregnancy,  or  uterine  disease. 
The  affection  of  sight  in  all  these  cases  probably  depends  upon  dis- 
turbances of  the  circulation  caused  by  direct  or  reflex  irritation  of  the 
vaso-motor  nerves.  An  epileptic  attack  may  be  succeeded  by  a  temporary 
enfeeblement  of  sight,  which  usually  disappears  rapidly,  but  may  become 
more  or  less  permanent  when  the  attacks  are  frequently  repeated.  Uni- 
lateral blindness  occurring  in  paroxysms,  and  generally  lasting  only  a  few 
minutes,  is  sometimes  observed  in  the  midst  of  perfect  health,  and  may 
possibly  be  regarded  as  a  vaso-motor  epilepsy.  I  myself  suffered  for 
upwards  of  ten  years  from  this  affection.  The  blindness  was  preceded  for 
a  few  seconds  by  a  feeling  of  tension  and  fulness  of  the  right  eye,  then  the 
central  portion  of  the  visual  field  became  suddenly  clouded,  but  the  dark- 
ness spread  with  such  rapidity  that  the  right  eye  appeared  to  have  become 
almost  instantaneously  blind.  Each  attack  lasted  from  one  to  three 
minutes,  and  was  accompanied  at  times  by  momentary  and  very  slight 
confusion,  but  I  never  observed  that  it  was  followed  by  any  sjTnptom 
whatever.  I  could  sometimes  determine  an  attack  by  pressing  on  the  globe 
of  the  eye,  and  I  discovered  accidentally  thai,  I  could  bring  back  the  sight 
very  soon  by  bending  the  head  between  my  legs,  so  that  the  capillaries 
of  the  face  got  flushed ;  for  many  years  I  took  a  considerable  interest  in 
experimenting  upon  what  I  regarded  as  an  interesting  but  innocent  affec- 
tion. I  always  attributed  the  attack  to  excessive  smoking,  and  becoming 
afraid  twelve  years  ago  that  the  sight  of  the  right  eye  was  gradually 
getting  weaker,  I  gave  up  smoking,  and  from  that  time  till  now  I  have  not 
had  an  attack.     Three  years  ago  I  recommenced  smoking  in  moderation. 


S76  DISEASES  OF  THE 

but  liave  had  no  return  of  the  paroxysmal  u.nilateral  blindness,  although  I 
have  had  some  attacks  of  what  will  be  immediately  described  as  scintil- 
lating scotoma.  The  amaurosis,  which  results  from  exhaustion,  debihty, 
hsematemesis,  profuse  menorrhagia,  or  other  severe  loss  of  blood,  is  possibly 
caused  by  ansemia  and  subsequent  serous  eflPasion  into  the  ventricles  of 
the  brain.  The  blindness  in  these  cases  is  often  temporary,  and  dis- 
appears under  tonic  and  stimulating  treatment ;  at  other  times  it  is  repeated 
after  every  return  of  the  bleeding,  and  may  become  permanent,  so  that 
the  prognosis  is  doubtful.  The  ophthalmoscopic  appearances  are  generally 
negative,  or  at  most  only  show  signs  of  diminished  supply  of  arterial  blood, 
with  or  without  congestion  of  the  veins.  In  some  few  cases,  especially  in 
the  heemorrhagic  or  scorbutic  diathesis,  smaU.  haemorrhages  may  be 
observed  in  the  neighbourhood  of  the  macula  lutea,  which  may  be  accom- 
panied by  sudden  bhndness.  In  other  cases  serous  transudation  and 
cloudiness  of  the  discs  are  observed,  followed  by  secondary  atrophy  of  the 
optic  nerves. 

The  amblyopia  and  amaurosis  which  follow  acute  diseases,  and  various 
toxic  agents,  are  of  obscure  origin.  The  most  common  toxic  agents  which 
cause  amblyopia  are  lead,  alcohol,  tobacco,  opium,  belladonna,  quinine,  and 
santonine.  Some  of  these  agents,  such  as  lead,  catise  the  affections  of  sight 
by  inducing  changes  in  the  tissues  of  the  brain  and  other  parts  of  the 
nervous  system,  or  in  the  vascular  system. 

Of  the  acute  diseases  typhus  fever  is  most  frequently  followed  by 
amblyopia  or  amaurosis.  The  affection  of  sight  comes  on  suddenly  during 
convalescence,  in  the  form  of  an  eccentric,  sharply-defined  defect  of  the 
field  of  vision,  a  central  scotoma,  or  even  amaurosis.  The  ophthal- 
moscopic appearances  are  negative,  and  it  is  probable  that  the  affection  is 
due  to  a  cerebral  lesion.  Amaurosis  is  occasionally  one  of  the  sequelae  of 
scarlet  fever,  and  appears  to  be  caused  by  hydrocephalus  interns  or  oedema 
of  the  base  of  the  brain.  Similar  affections  of  vision  may  also  result  from 
measles,  erysipelas  of  the  head,  pnevmionia,  and  other  acute  diseases. 

§  209.  Symptoms. — The  symptoms  of  functional  amblyopia  and 
amaurosis  are  the  same  as  those  which  are  observed  in  organic 
diseases  of  the  optic  nerve,  except  that  no  ophthalmoscopic 
changes  are  observable  in  the  former.  Vision  presents  four 
distinct  alterations  in  amblyopia : — 1,  Diminution  in  the  acute- 
ness  of  vision  ;  2,  Alterations  in  the  field  of  vision ;  S,  Disorders 
of  the  perception  of  light ;  and  4,  Disorders  of  the  perception  of 
colours. 

(1)  Dim^inution  in  the  Acuteness  of  Vision. — The  patient 
sees  objects  through  a  mist ;  he  has  a  difficulty  in  distinguishing 
minute  objects,  or  at  times  may  observe  a  dark  spot  in  the 
centre  of  vision. 


NERVES  OF   SPECIAL  SENSE,  377 

Tests  of  the  Acuteness  of  Vision. — The  acuteness  of  vision  is  usually 
tested  by  asking  the  patient  to  read  print  of  a  certain  size  of  type,  and  at 
definite  distances.  The  scales  of  test  print  which  are  usually  used  in 
England  are  those  of  Snellen,  Jaeger,  and  Walton.  In  Snellen's  scale  the 
size  of  type  is  numbered  according  to  the  distance  in  feet,  at  which  the 
print  can  be  read  by  the  normal  eye.  No.  3  of  the  scale  can,  for  instance, 
be  read  by  a  normal  eye  in  a  moderate  light  at  a  distance  of  three  feet. 
The  acuteness  of  vision  is  expressed  by  a  fraction,  of  which  the  denominator 
is  the  number  of  the  test  type,  and  the  numerator  the  distance  in  feet,  at 
which  it  can  be  read.  Other  simple  devices  must  be  adopted  when  a  person 
cannot  read.     The  sight  of  each  eye  must  always  be  tested  separately. 

(2)  Alterations  in  the  Field  of  Vision. — Eestriction  of  the 
field  of  vision  usually  accompanies  considerable  change  in  the 
acuteness  of  vision.  The  field  of  vision  may  be  altered  in 
several  ways,  but  the  form  usually  observed  in  functional 
amblyopia  begins  at  the  margin  of  the  field,  and  progresses 
concentrically  until  only  a  small  central  area  is  left. 

Scotoma. — The  first  loss  of  vision  may  appear  in  the  centre 
of  the  field,  constituting  a  central  scotoma.  This  dark  spot  is 
usually  at  the  point  of  fixation  ;  it  is  small  at  first,  but  gradually 
extends,  and  assumes  a  round,  oval,  or  irregular  form.  At  times, 
the  whole  of  the  field  of  vision  is  covered  with  scotomata,  which 
appear  like  small  points  when  the  patient  looks  at  a  near  object, 
but  become  larger  when  he  looks  at  a  distant  object.  Concentric 
narrowing  of  the  field  is  often  present.  This  form  is  observed  in 
amblyopia,  caused  by  the  abuse  of  tobacco  and  alcohol. 

Scintillating  Scotoma. — This  form  of  disordered  vision  appears 
at  the  onset  to  consist  of  a  scotoma,  generally  affecting  both  eyes, 
though  not  to  the  same  extent.  The  loss  of  sight  is  limited  at 
first  to  a  small  portion  of  the  visual  field,  which  may  be  centric 
or  eccentric;  it  soon  spreads,  and  as  a  rule  one  lateral  half  of 
the  field  of  vision  is  affected.  At  other  times  the  affection  of 
vision  is  central,  and  images- of  surrounding  objects  to  which  the 
axes  of  vision  are  not  directed  may  be  visible  as  usual.  The 
blindness  is  accompanied  by  spectral  appearances,  which,  as  a 
rule,  become  gradually  developed  as  the  black  spot  extends.  In 
their  simplest  form  they  consist  of  a  luminous  border  sur- 
rounding more  or  less  completely  the  blind  area,  and  widening 
as  the  latter  expands.^     This  luminous  circle  or  arc  is  subject 

*  Liveing.  On  megrim,  sick-headache,  and  some  allied  disorders.  Lond.,1873.  p.  75. 


378  DISEASES  OF  THE 

to  a  rapid  oscillatory  movement,  which  has  been  variously 
described  by  different  observers.  In  the  more  pronounced  forms 
of  the  affection  the  luminous  border  assumes  a  zigzag  outline, 
which  has  been  compared  to  the  angles  of  a  fortification.  It  is 
also  fringed  by  gorgeous  colours,  which  are  in  continual  trembling 
movement,  or  appear  to  "coruscate"  or  to  emit  a  "shower  of 
sparks."  The  phenomenon  generally  lasts  from  a  quarter  to  half 
an  hour,  and  then  gradually  passes  off.  The  few  times  that  I 
have  experienced  this  phenomenon  I  could  only  compare  the 
luminous  arc  to  a  horse  shoe  rainbow  with  its  convexity  directed 
upwards,  and  without  either  zigzag  outline  or  oscillatory  move- 
ment. I  could  always  see  objects  clearly  in  the  lower  half  of  the 
field  of  vision,  and  the  partial  blindness  passed  off  in  less  than 
five  minutes,  without  being  followed  by  any  other  symptom. 

The  attack  is,  however,  often  accompanied  by  transitory  im- 
pairment of  cutaneous  sensibility,  along  with  tingling,  numbness, 
or  formication,  as  well  as  by  deafness,  loss  of  taste,  embarrass- 
ment of  speech  (aphasia),  momentary  incoherence,  transitory 
paresis  of  one  of  the  limbs,  vertigo,  and  nausea,  and  it  is  usually 
followed  by  an  attack  of  migraine.  Ophthalmoscopic  examina- 
tion of  the  eye  during  the  attack  has  not  revealed  any  abnormal 
appearances  of  the  fundus.-^ 

The  similarity  of  scintillating  scotoma  to  a  visual  epileptic 
aura,  and  of  some  of  the  symptoms  with  which  it  is  associated, 
such  as  the  transitory  aphasia,  to  a  slight  epileptic  attack,  tend 
to  show  that  the  optic  phenomena  are  caused  by  a  discharging 
lesion  of  the  cortex  of  the  brain. 

Test  of  the  Field  of  Vision. — The  most  ready  test  of  the  field  of  vision 
is  to  direct  the  patient  to  fix  one  eye,  the  other  being  closed,  on  the  corre- 
sponding eye  of  the  operator,  and  the  latter  then  moves  his  hand  to  the 
right,  left,  above,  and  below,  and  at  a  certain  distance  from  the  fijsed  point 
as  a  centre.  If  the  field  of  vision  be  limited  in  any  particular  direction, 
the  observer  will  have  to  approach  his  hand  nearer  and  nearer  to  the  point 
on  which  the  patient's  eye  is  fixed  before  it  is  seen,  and  thus  any  serious 
departure  from*  the  normal  limit  can  be  readily  detected.  If  greater 
accuracy  be  required,  the  field  of  vision  must  be  measured  by  means  of 
the  "  mapping  system,"  or  by  the  perimeter,  for  a  description  of  which  the 
reader  is  referred  to  ophthalmological  works. 

(3)  Disorders  of  the  Perception  of  Light. — There  are  several 

1  Liveing.    Op,  cit.,  p.  80 


NERVES  OF  SPECIAL  SENSE. 


379 


varieties  of  partial  optic  ansesthesia  in  which  the  ophthalmoscopic 
appearances  may  be  negative.  Sometimes  the  patient  cannot 
see  at  night,  a  condition  which  is  called  hemeralopia;  at  other 
times  sight  is  defective  in  daylight,  and  this  condition  is  called 
nyctalopia. 

(4)  Disorders  of  the  Perception  of  Colours  (Dyschromatopsia, 
Achromatopsia). — Particular  attention  has  been  drawn  by  Gale- 
zowski  and  others  to  the  fact  that  there  may  be  a  defect  in  colour 
vision  even  when  the  acuteness  of  vision  is  very  little  impaired. 
On  the  other  hand,  colour  vision  may  be  little  affected  when 
there  is  considerable  limitation  of  the  field  of  vision.  The  area 
of  the  field  of  vision  varies  for  each  colour.  If  coloured  objects 
are  moved  from  the  centre  to  the  periphery  the  first  simple 
colour  to  be  unperceived  is  green,  the  next  red,  while  yellow  and 
blue  are  lost  near  the  edge  of  the  field.  If  the  distance  at  which 
each  colour  ceases  to  be  distinguished  is  marked  upon  a  chart,  a 
series  of  concentric  lines  is  obtained  as  shown  in  Fig.  33. 

Tests  of  Colour  Visio7i. — (1)  It  must  be  ascertained  whether  the  patient 
can  identify  and  name  certain  colours.  For  this  purpose  Galezowski's  scale 
of  colours  may  be  employed.  Eleven  colours — ^red,  red-orange,  orange, 
orange-yellow,  yellow,  yellow-green,  green,  green- blue,  blue,  blue-violet,  and 
violet — are  arranged  in  this  scale  in  the  order  in  which  they  occui-  in  the 
spectrum. 

Fig.  33. 


Fig.  33  (after  Gowers).  Diagram  showing  the  Fields  of  Colour  Vision  in  a  normal 
emmetropic  eye  on  a  dull  day. — The  fields  are  each  rather  smaller  than  on  a 
bright  day.  The  asterisk  indicates  the  fixing  point,  the  black  dot  the  position 
of  the  blind  spot.     (Usually  the  blue  field  is  larger  than  the  yellow.) 


380  DISEASES   OF   THE 

(2)  According  to  the  second  method,  which  was  originally  introduced  by 
Sir  J.  Herschell  in  the  case  of  Dalton,  the  patient  is  asked  to  match  a 
given  colour  from  a  number  of  others  presented  to  him.  Skeins  of 
coloured  wool  are  useful  for  this  purpose. 

In  amblyopia  the  order  in  which  the  perception  of  the  colours 
is  lost  is  usually  that  in  which  the  fields  are  arranged  on  the 
retina,  the  first  defect  being  for  green,  then  red,  while  blue  and 
yellow  are  subsequently  lost.  The  condition  in  which  central 
vision  for  the  perception  of  one  or  more  colours  is  much 
restricted  is  named  dyschromatopsia.  This  group  comprises  a 
large  number  of  transitional  forms,  from  normal  vision  up  to 
total  colour  blindness,  or  achromatopsia.  In  this  latter  variety 
the  subject  can  only  perceive  differences  between  darkness  and 
light,  and  the  different  degrees  of  intensity  of  light.  It  is  rarely 
met  with  except  as  a  result  of  organic  disease. 

Congenital  Colour  Blindness. — This  form  of  colour  blindness 
is  not  usually  accompanied  by  any  other  defect  of  vision.  The 
sight  of  the  colour-blind  is  best  explained  by  supposing,  as 
originally  pointed  out  by  Sir  J.  Herschell  in  the  case  of  Dalton, 
that  their  vision  is  dichromic,  and  that  the  faculty  of  appreciating 
one  of  the  fundamental  colours  is  altogether  wanting.  There  are 
three  varieties  of  colour  blindness,  namely — (1)  Red-blindness; 
(2)  Green-blindness;  and  (3)  Violet-blindness.^ 

Dalton  suffered  from  the  first  variety;  he  imagined  that 
diluted  black  ink  gives  a  colour  much  resembling  a  florid  com- 
plexion; blood  appeared  to  him  not  unlike  in  colour  to  that 
called  bottle-green;  and  he  could  not  distinguish  between  the 
colour  of  a  ripe  cherry  and  that  of  the  leaf. 

Dalton  saw  only  two,  or  at  most  three,  colours  in  the  spectrum.  "  My 
yeUow,"  he  says,  "  comprehends  the  red,  yellow,  and  green  of  others,  and 
my  blue  coincides  with  theirs.  That  part  of  the  image  which  others  call 
red,  appears  to  me  little  more  than  a  shade  or  defect  of  Light ;  after  that 
the  orange,  yeUow,  and  green  seem  one  colour,  which  descends  pretty 
uniformly  from  an  intense  to  a  rare  yellow,  making  what  I  should  call 
different  shades  of  yellow."  Green  and  blue  were  with  him  strongly  con- 
trasted, and  the  purple  appeared  blue  and  much  darkened  and  condensed. 
The  account  given  by  Bonders^  of  colour  bhndness  is  so  lucid  and  scientific 

1  See  Jefferies  (B.  J.).  Colour  blindness,  its  dangers  and  its  detection.  Boston, 
1879.    p.  41. 

*  Bonders  (Prof.  F.  C).  "  Remarks  on  Colour  and  Colour-blindness."  British 
Medical  Journal,  Vol.  II.,  1880,  p.  767. 


NERVES   OF   SPECIAL   SENSE.  381 

that  we  cannot  do  better  than  quote  his  own  words  in  full.  In  reference 
to  red-blindness  and  green-blindness  he  says  :  "  Sir  J.  Herschell  supposed, 
and  Clerk  Maxwell  proved,  that  the  colour  blind  see  only  two  colours — 
they  have  a  dichromic  system.  In  the  spectrum  they  see  only  two  colours : 
that  on  the  red  side  we  call  the  toarm,  W  ;  that  on  the  blue  side  we  call 
the  cold,  C.     They  see  a  grey  stripe,  N,  between  them  ;  there,  where 

dW  dC 


W  C 

Green,  yellow,  orange,  and  red  belong  to  W ;  blue  and  violet  to  C.  W  and 
C  they  distinguish  easily.  But  the  different  colours  belonging  to  W,  or 
to  C,  are  confused  by  the  coloiu-  blind ;  such  differences  as  they  do  dis- 
tinguish between  them  are  differences  of  saturation  and  intensity. 

"  Trying  to  apply  our  words  to  their  sensations,  their  W  they  call  red, 
if  much  saturated  (and  brilliant) ;  yellow  if  intense  and  moderately  satu- 
rated ;  green  if  pale.  And  they  often  decide  rightly.  But  red  may  be  pale, 
yellow  dark,  green  much  saturated  ;  and  then  confusion  is  inevitable. 
With  the  different  colours  belonging  to  C  they  have  no  success  at  all ;  they 
call  them  all  bluish  or  blue.  The  stripe  N  produces  a  second  series  of  con- 
fusions. It  is  found,  as  we  saw,  in  the  bluish  green.  Now,  pink  is  another 
neutral  colom*,  producing  the  same  equilibrium  of  W  and  C,  so  that  it  also 
is  seen  as  grey.  Bluish  green,  pink,  and  grey  are,  therefore,  the  same,  all 
grey.     But  the  least  predominance  of  W  or  C  is  recognised. 

"  All  this  holds  good  as  well  for  red-blindness  as  for  green-blindness.  It 
is  inherent  in  the  dichromic  system.  But  there  are  differences.  C  seems 
the  same  for  both,  but  W  is  not.  In  the  green-blind,  W,  in  its  curve  of 
intensity,  scarcely  differs  from  our  red  ;  but  in  the  red-blind  it  approaches 
gi-een,  and  in  some  cases  reaches  it.  Here  the  spectrum  is  darker  and 
shorter  at  the  red  end ;  the  maximum  of  intensity  is  much  further  off,  and 
N  is  nearer  to  the  blue. 

"  Hence  many  differences  as  to  the  confusion  of  colours.  The  red-blind 
person  sees  as  black  the  dark-red  brown  of  the  green-blind.  The  same  red 
and  orange  correspond  to  a  dark  yellow,  or  green  in  the  former,  to  a  light 
in  the  latter,  &c.  Moreover,  most  remarkable  differences  occur  in  regard 
to  the  stripe  N ;  that  of  the  green-blind  is  W  for  the  r'ed-bhnd ;  that  of  the 
red-blind  is  C  for  the  green-blind ;  and  also  there  is  a  pink,  which  is  blue 
for  the  former,  red  for  the  latter. 

"  All  the  coloiu-s  of  our  circle,  as  the  red-blind  or  the  green-blind  see 
them,  can  be  made  up  by  yellow  and  blue,  with  black  and  white.  The 
differences  are  seen  at  once  if  represented,  as  in  the  diagram  before  you,  on 
two  circles  inside  the  circle  of  our  colours.  In  both  the  same  tones  recur 
twice,  and  twice  the  neutral  stripe  N — once  between  W  and  C  in  the  green- 
ish blue,  and  once  between  W  and  C  in  the  pink.  But  to  the  red  corre- 
sponds a  much  darker  yeUow  in  the  red-blind,  to  the  bluish-green  a  darker 
blue  in  the  green-blind.  W  and  C  must  be  considered  as  complimentary 
colours.     To  which  of  our  sensations  they  correspond  cannot  well  be  told ; 


382  DISEASES   OF  THE 

probably  0  is  blue  or  violet,  W  is  yellow,  approaching  to  red  in  green- 
blindness,  to  green  in  red-blindness. 

"  Violet  blindness  is  rare.  Jn  it  the  spectrum  is  much  shortened  at  the 
violet,  and  shghtly  shortened  at  the  red  end ;  the  maximum  of  intensity 
being  on  the  yeUowish-green.  A  broad  greyish  band  separates  the  two 
colours,  its  middle  being  about  the  yellow.  W,  which  is  called  red,  is  not 
intense,  but  rather  saturated  ;  C,  which  he  calls  blue,  is  more  intense,  but 
little  saturated.  Now  yellow  objects  appear  colourless,  pale  green  and  pale 
blue  also  colourless ;  the  blue  of  the  sky  is  grey.  Saturated  blue  and  green 
look  alike,  but  the  blue  looks  darker.  Blue  and  violet  woollens  of  very 
diflferent  degrees  of  saturation  are  sorted  apart,  though  very  slowly.  The 
sensibility  for  light,  which  does  not  differ  from  the  normal  in  green-blind- 
ness and  in  red-blindness,  is  much  diminished  in  violet-bhndness  ;  and  the 
sensibihty  for  colour  still  more  so.  The  acuity  for  vision  is  normal.  No 
pathological  changes  are  visible  in  the  eye-ground." 

DISEASES  OF  THE   OPTIC  COMMISSURE  AND   TRACTS. 

The  crossing  of  the  fibres  of  the  optic  tracts  has  already  been 
described.  The  subjoined  diagram,  borrowed  from  Charcot, 
explains  readily  the  symptoms  caused  by  lesions  of  these  parts. 

The  lesions  which  usually  affect  the  optic  tracts  and  commis- 
sure are  circumscribed  affections  of  the  bones  and  membranes  of 
the  brain  or  injuries  of  the  base  of  the  skull. 

§  210.  Symptoms.— The  characteristic  feature  of  an  affection 
of  the  optic  tract  is  an  enfeeble  ment  or  abolition  of  sight  of  one 
lateral  half  of  the  retinae.  The  blind  half  of  the  retina  is  sepa- 
rated from  the  sensitive  half  by  a  vertical  line,  the  limit  between 
the  two  portions  being  sharply  defined.  When  this  condition  is 
described  with  reference  to  the  field  of  vision  it  is  called  hemi- 
anopsia,  and  to  the  retina  hemiopia.  Temporal  hemianopsia, 
the  condition  in  which  one-half  of  the  field  of  vision  on  the 
externa],  or  temporal  side  of  the  eye,  is  diminished  or  lost, 
corresponds  to  nasal  hemiopia,  the  condition  in  which  the  inner  or 
nasal  half  of  the  retina  is  ansesthetic. 

Equilateral,  or  Homonymous  Hemianopsia. — When  the  left 
optic  tract  is  compressed  by  a  tumour  {Fig.  34,  K),  the  two  left 
halves  of  the  retinae — the  outer  of  one  and  inner  half  of  the 
other — are  cut  off  from  the  cortex,  a  condition  which  causes  loss 
of  the  right  halves  of  the  field  of  vision,  constituting  right  lateral 
hemianopsia.    The  affected  portions  of  the  retinae  are  those 


NERVES  OF  SPECIAL  SENSE.  383 

which  are  associated  in  their  functions,  and  the  condition  has 
consequently  been  called  equilateral  or  homonymous  hemi' 
anopsia. 

Sometimes  homonymous  hemianopsia  of  one  side  is  followed 
by  progressive  restriction  of  the  fields  of  vision  on  the  sensitive 
side  until  ultimately  complete  amaurosis  is  established.  This 
condition  is  named  bilateral  hemianopsia,^  and  when  complete 
blindness  is  established  it  is  named  double  cerebral  amaurosis,^ 
because  the  lesions  have  been  found  in  such  cases  in  the  cerebral 
hemispheres.  Bilateral  hemianopsia  may  sometimes  be  incom- 
plete, and  of  this  group  Wilbrand^  distinguishes  the  following 
three  varieties,  each  being  subdivided  into  two  forms  : — (1)  Com- 
plete left-sided  associated  with  incomplete  right-sided  lateral 
hemianopsia,  comprising  (a)  defect  of  the  upper  quadrant,  and 
(6)  defect  of  the  lower  quadrant  of  the  right  half  of  the  field  of 
vision;  (2)  bilateral  incomplete  symmetrical  lateral  hemianopsia, 
comprising  (a)  defect  of  both  upper,  and  (b)  defect  of  both  lower 
quadrants  of  the  field  of  vision ;  (3)  bilateral  incomplete  crossed 
lateral  hemianopsia,  comprising  {a)  defect  of  the  upper  quad- 
rant of  the  left  and  of  the  lower  quadrant  of  the  right  half  of 
the  field  of  vision,  and  (6)  defect  of  the  lower  quadrant  of  the 
left  and  of  the  upper  quadrant  of  the  right  half  of  the  field  of 
vision.  In  many  cases  a  quadrant,  or  three-fourths  of  the  half 
of  the  field  of  vision  only  may  be  lost ;  and  Nettleship*  pro- 
poses to  name  these  cases  tetrato-hemianopsia.  Such  cases  are 
apt  to  be  associated  with  a  monoplegia  on  the  same  side  as  the 
defect  in  the  field  of  vision.  In  a  case  recorded  by  Berry ^  the 
lower  quadrant  of  the  field  of  vision  was  blind,  and  the  leg  on 
the  same  side  was  paralysed,  so  that  the  patient  could  not  see 
the  latter.  In  a  case  reported  by  Bernhardt,^  the  patient  had  an 
attack  of  hemiplegia  with  dimness  of  vision.     She  recovered 


^  See  Wilbrand  (H.).  Ueber  Hemianopsia  und  ihr  Verhaltniss  zur  topischen 
Diagnose  der  Gehirnkrankheiten.     Berl.,  1881.     p.  150. 

»  Nettleship  (E.).    British  MedicalJournal.     Vol.  II.,  1882,  p.  1083. 
^  Op.  cit.,  p.  19]. 

*  Nettleship,    Loc.  cit, 

*  Berry  (G.  A.).  "  Subjective  symptoms  in  eye  diseases."  Edinburgh  Medical 
Journal,  1882,  p.  684. 

'  Bernhardt.  "  Beitrag  zur  Lehre  von  den  Storungen  der  Sensibilitat  und  des 
Sehvermbgens  bei  Lasionen  dea  Hirnmanteb.'*  Arch.  f.  Psychiat.,  Bd.  XII.,  1882, 
p.  780. 


884 


DISEASES   OF  THE 


from  the  hemiplegia,  but  sensation,  especially  the  muscular  sense, 
became  impaired  in  the  right  arm.  The  defect  of  sight  con- 
sisted of  an  area  of  indistinct  vision,  which  occupied  the  upper 
three-fourths  of  the  right  half  of  each  eye,  so  that  this  patient 
also  could  not  see  her  partially  paralysed  hand.  In  some  cases 
there  is  no  diminution  of  the  acuteness  of  vision,  but  the  per- 
ception of  colour  is  diminished  or  lost^  iu  one-half  of  the  visual 
fields;  these  cases  are  named  hemi-achromatopsia. 

Crossed  Hemianopsia. — In  crossed  hemianopsia  the  inner  or 
outer  halves  of  both  retinae  are  ansesthetic.  When  the  lesion  is 
situated  over  the  centre  of  the  commissure  {Fig.  34,  T),  the  inner 
halves  of  both  retinse  are  affected.  With  reference  to  the  fields 
of  vision,  this  condition  is  called  double  temporal  hemianopsia. 
In  these  cases  there  is  a  superposition  of  the  images  formed  on 
the  outer  halves  of  the  retinse,  consequently  the  patients  are 
often  able  to  read  the  smallest  print,  but  experience  considerable 
difficulty  in  walkiog.     Double  nasal  hemianopsia  is  rare,  and 

Fig.  34. 


Fig.  34  (after  Charcot).  Diagram  of  Decussation  of  the  Optic  Tracts. — T,  Semi- 
decussation in  the  chiasma  ;  TQ,  Decussation  of  fibres  posterior  to  the  external 
geniculate  bodies  (CG) ;  a' b,  Fibres  which  do  not  decussate  in  the  chiasma; 
6'  a',  Fibres  coming  from  the  right  eye,  and  coming  together  in  the  left  hemi- 
sphere (LOG) ;  K,  Lesion  of  the  left  optic  tract  producing  right  lateral  hemia- 
nopsia; A,  Lesion  in  the  left  hemisphere  (LOG),  produces  crossed  amblyopia 
(right  eye).  T,  Lesion  producing  temporal  hemianopsia;  N  N,  Lesion  producing 
nasal  hemianopsia. 


'Samelsohn.     "  Zur  Frage  des  Farbensinncentrums." 
Wissensch.,  Bd.  XIX.,  1881,  p.  850. 


Centralbl.  f.  d.  med. 


NERVES  OF  SPECIAL  SENSE.  385 

results  from  a  double  lesion  {Fig.  34,  N,  N).  In  this  condition 
the  functional  disturbances  produced  are  great,  and  the  patient 
can  neither  work  nor  guide  himself. 

The  course  of  the  fibres  of  the  optic  tract  between  the  external  geniculate 
body  and  the  cortex  of  the  brain  is  not  well  ascertained.  Both  anatomical 
and  physiological,  as  well  as  pathological  observations  make  it  certain  that 
most,  if  not  all,  of  the  fibres  of  the  tracts  terminate  in  the  cortex  of  the 
occipital  lobes,  but  the  course  of  the  fibres  in  the  intervening  space  between 
the  cortex  and  external  geniculate  body  is  the  subject  which  has  excited 
the  greatest  controversy.  An  endeavour  has  been  made  by  Belloiiard,^ 
Wilbrand,*^  F^re,^  and  others,  to  determine  this  question  by  an  analysis 
of  pathological  observations.  Hysterical  hemiansesthesia,  for  instance, 
is  associated  with  amblyopia  of  the  eye  on  the  affected  side.  Now,  the 
most  reasonable  explanation  of  hysterical  hemianaesthesia  is  that  there 
is  a  diminution  or  abolition  of  the  function  of  the  sensory  portion  of 
the  cortex  of  the  opposite  hemisphere,  or  of  the  centripetal  conducting 
paths  in  their  passage  through  the  posterior  portion  of  the  internal 
capsule  and  optic  radiations  of  Gratiolet.  And  in  some  cases  in  which 
the  posterior  part  of  the  internal  capsule  was  found  diseased  after 
death  the  hemiansesthesia  of  the  opposite  half  of  the  body  which  had 
existed  diu-ing  life  was  associated  vdth  amblyopia  of  the  eye  on  the  anaes- 
thestic  side.*  A  case  is  also  reported  by  Petrina^  of  a  man,  53  years  of 
age,  who,  after  a  fall  on  the  back  of  his  head,  complained  of  diminution  of 
the  acuteness  of  vision.  A  careful  examination  showed  that  the  patient 
could  neither  distinguish  colours,  form,  nor  distance  with  the  left  eye,  and 
he  was  quite  unable  to  read  or  write  when  the  right  eye  was  closed.  The 
sight  of  the  right  eye  was  good,  although  not  so  good  as  before  the  acci- 
dent. At  the  autopsy,  the  internal  table  of  the  skull  was  found  fissured 
along  the  parieto-occipital  suture  on  the  right  side.  The  cortex  of  the 
right  occipital  lobe  generally  was  found  of  yellowish-brown  colour,  and 
gelatinous  consistence,  while  the  subjacent  white  substance  was  very 
dense.  A  microscopic  examination  led  to  the  belief  that  the  cortical 
changes  were  consecutive  to  a  meningeal  haemorrhage.  But  if  the  fibres  of 
each  optic  tract  were  connected  with  the  cortex  of  the  corresponding 
hemisphere,  a  functional  or  organic  lesion  of  the  posterior  part  of  the 
internal  capsule,  or  of  the  cortical  visual  centre,  should  give  rise  to  homo- 
nymous hemiopia,  and  not  to  amblyopia  of  the  eye  opposite  to  the  lesion. 
In  order  to  meet  this  difficulty,  Charcot  assumed  that  there  is  a  supple- 

'  Bellouard.    De  I'hemianopsie.     Paris,  1880.    p.  107. 

*  Wilbrand.     Op.  cit. 

^  ¥er4  (Ch.).  Contribution  a  I'^tude  des  troubles  functionnels  de  la  vision  par 
lesions  cerebrales.     Paris,  1882. 

*Muller  (Fr.).  " Neuropathologische  studien,"  Berl.  klin.  Wochensch.,  Bd. 
XV.,  1878,  pp.  284  and  300. 

*  Petrina.    Ueber  Sensibilitats  storungen  bei  Hirnlasionen.    Prag.,  1881.    p.  21. 

VOL.  L  Z 


386  DISEASES  OF  THE 

mentary  crossing  of  fibres  of  the  optic  tracts  in  tlie  corpora  quadrigemina 
{Fig.  34,  TQ),  so  that  the  fibres  which  are  derived  from  one  eye  all  pass  to 
the  cortex  of  the  opposite  hemisphere.  But  if  aU  the  fibres  from  one  eye 
which  had  not  crossed  in  the  commissm'e  passed  over  to  the  opposite  hemi- 
sphere through  the  corpora  quadrigemina,  then  it  might  be  expected  that 
interruption  of  the  optic  fibres  in  the  substance  of  the  hemisphere  would 
cause  absolute  blindness  of  the  opposite  eye  instead  of  amblyopia.  The 
eyes,  however,  are  bilaterally  associated  in  their  actions,  and  impulses 
originating  in  the  affected  eye  may  be  supposed  to  find  their  way  to  the 
cortex  of  one  or  other  hemisphere  by  means  of  commissural  fibres. 

But  when  we  come  to  consider  the  various  circumstances  under  which 
hemiopia  arises,  it  wiU  be  seen  that  the  scheme  proposed  by  Charcot  by  no 
means  meets  all  the  difficulties  of  the  case. 

Hemianopsia  may  arise  as  (1)  a  transitory  symptom^  in  cases  of  cerebral 
hasmorrhage,  (2)  as  a  temporary  and  functional  symptom  in  migraine,  and 
(3)  as  a  permanent  affection  in  organic  diseases  of  the  brain.  The  tran- 
sitory hemiopia  of  cerebral  haemorrhage  is  possibly  caused  by  compression 
of  the  optic  tract  by  the  distension  of  the  hemisphere  produced  by  the 
blood  clot,  and  is  therefore  of  no  use  for  the  determination  of  the  present 
question.  The  temporary  hemianopsia,  which  sometimes  precedes  an  attack 
of  migraine,  is  doubtless  of  functional  origin.  The  imilateral  character  of 
the  headache  in  migraine  would  seem  to  indicate  that  the  hemiopia  is  caused 
by  a  functional  affection  of  one  hemisphere,  either  a  spasm  of  the  vessels 
or  a  discharge  from  the  cortical  visual  centre  followed  by  temporary  loss  of 
fimction.  So  far,  therefore,  this  form  of  hemiopia  favom-s  the  opinion  that 
the  fibres  of  each  optic  tract  are  connected  with  the  cortex  of  the  corre- 
sponding hemisphere,  although  no  great  value  can  be  attached  to  this 
supposition  in  the  absence  of  other  evidence. 

With  regard  to  the  permanent  hemianopsia  of  organic  disease  we  may 
at  once  exclude  from  our  consideration  aU  the  cases  which  are  caused  by 
tumours,  abscess,  and  voluminous  blood  clots,  inasmuch  as  in  them  the 
visual  defect  may  be  caused  by  direct  or  indirect  pressme  upon  one  of  the 
optic  tracts,  as  it  winds  round  the  crus  cerebri.  We  shall  also  reject  as  un- 
suited  to  our  purpose  aU  cases  of  local  softening  in  the  hemisphere  in  which 
the  lesion,  either  from  its  position  or  large  size,  is  likely  to  encroach  upon  the 
termination  of  the  optic  tract  in  the  external  geniculate  body,  inasmuch  as 
in  those  cases  the  hemianopsia  may  have  been  caused  by  direct  interference 
with  the  optic  tract  itself.  After  deducting  these  cases  only  a  very  few 
remain  in  which  disease  of  a  hemisphere  gave  rise  to  hemianopsia.  My 
colleague.  Dr.  Dreschfeld,^  has  described  a  case  of  left  hemiplegia  and 
hemiansesthesia,  accompanied  by  a  slight  degree  of  aphasia  and  left  hemi- 
anopsia. At  the  autopsy  three  smaU  hsemorrhages  were  found  in  the  centrum 

'  Gowers.  "  Transient  hemiopia  in  cerebral  disease."  Britisli  Medical  Journal, 
Vol.  II.,  3877,  p.  729. 

-  Dreschfeld  (J.).  "  Pathological  Contributions  on  the  course  of  the  optic  nerve 
fibres  in  the  brain."    Brain,  Vol.  IV.,  Lond.,  1881-2,  p.  543. 


NERVES  OF   SPECIAL   SENSE.  387 

ovale  of  the  right  hemisphere,  all  of  them  underlying  the  descending  frontal 
and  ascending  parietal  convolutions.  Another  haemorrhage  about  three 
lines  in  diameter  was  foimd  in  the  pulvinar  of  the  optic  thalamus,  which 
did  not  involve  the  geniculate  bodies  or  corpora  quadrigemina,  and  this 
lesion  was  the  most  likely  to  have  caused  the  hemianopsia.  In  a  case  re- 
ported by  Cm'schmann^  the  patient  had  drunk  by  mistake  sulphuric  acid,  and 
two  days  subsequently  he  had  an  embolus  of  the  right  brachial  artery ;  on 
the  following  day  he  complained  that  he  could  not  see  objects  on  his  left, 
and  on  examination  it  was  found  that  he  had  complete  left  hemianopsia. 
The  patient  died  at  the  end  of  nineteen  days  from  the  commencement,  and 
at  the  auto]3sy  were  found  signs  of  inflammation  of  the  internal  coat  of  the 
aorta,  which  had  been  propagated  by  extension  from  the  oesophagus, 
embolus  of  the  right  brachial  artery,  and  a  large  focus  of  softening  in 
the  right  occipital  lobe,  which  extended  to  the  surface  towards  the  median 
'  line  and  the  posterior  extremity  of  the  hemisphere. 

A  case  of  unilateral  epilepsy  of  the  left  side,  followed  by  partial 
paralysis  and  hemiansesthesia  of  that  side,  along  with  complete  left- 
sided  hemianopsia,  has  been  reported  by  Westphal.^  At  the  autopsy  it 
was  observed  that  the  convolutions  of  the  right  hemisphere  lying  behind 
the  ascending  parietal  convolution  were  smaller  and  softer  than  the 
corresponding  convolutions  on  the  opposite  side.  The  centrum  ovale  of 
the  occipital  lobe  was  softened,  and  the  disease  extended  as  far  for- 
wards as  the  medullary  substance  of  the  ascending  parietal  convolution, 
which  was  itself  healthy.  No  other  lesion  existed  in  either  hemisphere,  and 
it  is  specially  mentioned  that  the  optic  tract  and  optic  thalamus  on  the 
right  side  were  healthy.  The  cases  which  I  have  just  mentioned  are  the 
least  free  from  doubt  of  any  which  I  have  seen  reported  in  tending  to  prove 
that  the  fibres  of  each  optic  tract  are  connected  either  wholly  or  in  great 
part  with  the  cortex  of  the  same  hemisphere,  although  a  large  number  of 
more  or  less  similar  cases  might  be  quoted.  But  we  have  seen  that  cases 
are  not  wanting  which  seem  to  prove  that  all  the  fibres  of  one  optic  nerve 
are  connected  with  the  cortex  of  the  opposite  hemisphere,  and  consequently 
demanding  for  their  explanation  a  theory  of  a  supplementary  crossing  of 
fibres  in  the  corpora  quadrigemina  like  that  proposed  by  Charcot.  It  is 
somewhat  difficult  to  reconcile  these  two  series  of  facts  and  the  apparently 
contradictory  conclusions  to  which  they  seem  to  point.  It  appears  at  least 
to  be  certain  that  the  connection  of  the  optic  fibres  with  the  cortex  of  the 
hemispheres  is  by  no  means  so  simxjle  as  they  appear  in  the  scheme  pro- 
posed by  Charcot,  and  it  is  not  improbable  that  they  may  be  found  some- 
thing similar  to  the  kind  of  crossing  which  Munk  has  determined  in  dogs. 

1  Curschmann.  Hirschberg's  Centralbl,  1879,  p.  181,  quoted  by  F6t6.  Con- 
tribution a  I'etude  des  troubles  fonctionels  de  la  vision  par  le'sions  c^rebrales. 
Paris,  1882.     p.  179. 

^  Westphal.  "Zur  Frage  von  der  Localisation  der  unilaterale  Convulsionen  und 
Hemianopsia  bedingenden  Hirnerkrankungen."  Charity -Annalen,  Jahrg.  VI. 
(1879),  Berl.,  1881,  p.  342,  See  also  Westphal.  Charite-Annalen,  Jahrg.  VIL 
a882). 


388  DISEASES  OF   THE 

We  have  already  seen  that  central  vision  is  not  abohshed  in  the  hemiopia 
caused  by  disease  of  either  of  the  optic  tracts,  and  it  would  therefore  seem 
certain  that  the  macula  lutea  of  each  eye  must  be  connected  with  both 
hemispheres.  This  view  is  still  fiu-ther  strengthened  by  the  fact  that  in 
many  cases  of  hemiopia  the  blind  and  sensitive  portions  of  the  retinae  are 
separated  by  a  narrow  portion  in  which  vision  is  considerably  weakened. 
If,  as  we  suppose,  this  portion  of  the  retina  is  normally  supplied  by  fibres 
from  both  hemispheres,  interruption  of  the  conduction  of  the  fibres  from 
one  hemisphere  would  weaken  but  not  abolish  sight  in  it.  And  if  it  be 
granted  that  each  macula  lutea  is  connected  with  both  hemispheres,  it  is 
not  unreasonable  to  suppose  that  this  double  connection  may  sometimes 
extend  beyond  the  macula  lutea.  In  that  case  each  half  of  both  retinae 
would  be  connected  with  the  cortex  of  both  hemispheres,  so  that  injiu-y  of 
one  hemisphere  would  give  rise  to  amblyopia  of  both  eyes  ;  but  inasmuch 
as  the  cortex  of  one  hemisphere  is  more  freely  connected  with  the  retina  of 
the  opposite  eye  than  with  that  of  its  own  side,  what  we  should  meet  with 
would  be  great  amblyopia  of  the  eye  opposite  and  a  slight  diminution  of  the 
acuity  of  vision  of  the  eye  on  the  same  side  as  the  lesion.  This  condition  is, 
indeed,  what  is  generally  observed  in  cases  of  crossed  amblyopia,  inasmuch 
as  a  careful  perimetric  examination  always  reveals  a -slight  restriction  of  the 
field  of  vision  of  the  eye  on  the  side  of  the  lesion  (Landolt).^  And  again, 
in  cases  of  homonymous  hemianopsia  from  a  cerebral  lesion  it  is  not  uncom- 
mon to  find  some  peripheral  restriction  of  the  remaining  half  of  each  field  of 
vision,^  which  is  sometimes  more  marked  in  the  eye  on  the  side  of  the  lesion, 
and  at  other  times  in  the  opposite  one.  These  cases  would  seem  to  indicate 
that  both  halves  of  each  retina  are  connected,  although  in  an  unequal 
degree,  with  the  two  hemispheres,  and  if  this  be  the  case  a  supplementary 
crossing  of  fibres  must  still  be  supposed  to  exist,  although  not  to  the  extent 
assumed  by  Charcot.  It  is  unnecessary  to  pursue  this  subject  further  at 
present ;  the  visual  defects  caused  by  disease  of  the  hemispheres  will  be 
again  discussed  in  subsequent  pages. " 

The  prognosis  of  permanent  hemiopia  is  always  grave,  and 
the  treatment  must  depend  upon  the  cause  of  the  affection. 
Hemiopia  is,  indeed,  not  a  disease  of  itself,  but  a  valuable  sign 
of  other  diseases. 

DISEASES   OF   THE   OPTIC   NERVES. 

The  length  of  the  optic  nerves  renders  them  peculiarly  liable 
to  suffer  from  secondary  affections,  and  consequently  diseases 
of  these  nerves  stre  not  only  important  on  account  of  the  func- 

'  See  Ferrier.  "  On  cerebral  amblyopia  and  hemiopia."  Brain,  Vol.  III., 
1880-1,  p.  456. 

*  See  Fere.    Op.  cit.,  ]^.  2li.     See  also  Nettleship.    Loc,  cit. 


NERVES   OF   SPECIAL   SENSE.  389 

tional  disturbances  produced,  but  on  account  of  their  diagnostic 
significance  in  cerebral  and  spinal  affections. 

Diseases  of  the  Optic  Nerves  (Optic  Neuritis  and  Atrophy). 

§  211.  Etiology. — Optic  neuritis  may  be  caused  by  various 
iotracranial  diseases,  and  of  these  tumour  of  the  brain  is  probably 
the  most  important. 

Hydrocephalus,  whether  it  be  primary,  or  secondary  to 
pressure  on  the  veins  of  Galen  or  the  lateral  sinuses,  also  gives 
rise  to  optic  neuritis.  Abscess  rarely  occasions  optic  neuritis, 
and  it  is  a  still  rarer  symptom  of  circumscribed  haemorrhage 
and  softening  of  the  brain  from  embolism  or  thrombosis.  In 
cases  of  haemorrhage  with  associated  double  optic  neuritis  the 
possible  presence  of  a  glioma  as  the  cause  of  the  hsemorrhage 
should  never  be  overlooked. 

Basal  meningitis,  as  well  as  meningeal  haemorrhages  and 
thrombosis  of  the  cavernous  sinus,  may  give  rise  to  inflamma- 
tion of  the  optic  nerves.  The  reason  why  basal  meningitis 
occasions  optic  neuritis  is  manifest  when  the  anatomical  relation 
of  the  affected  membranes  to  the  optic  tracts,  commissure,  and 
nerves  is  considered. 

A  second  group  of  inflammatory  states  of  the  optic  nerves  is 
determined  by  extracranial  causes.  Amongst  such  causes  must 
be  mentioned  orbital  tumours,  inflammatory  processes  in  the 
orbit,  as  periostitis,  cellulitis,  abscesses,  caries,  haemorrhage, 
congenital  deformities,  and  hyperostosis  producing  narrowing  of 
the  optic  foraminae.  A  moderate  degree  of  optic  neuritis  was 
observed  by  Dr.  AUbutt^  in  cases  of  injury  of  the  cervical  por- 
tion of  the  spine,  and  more  or  less  similar  cases  have  been 
described  by  Mooren^  and  Thorowgood  f  while  congestion  of  the 
disc  has  been  observed  by  Abadie*  and  Gowers^  in  cases  of  caries 
of  the  cervical  vertebrae.     Atrophy  of  the  disc  was  observed  by 

1  Allbutt  (T.  S.).  The  ophthalmoscope  in  diseases  of  the  nervous  system  and 
kidneys.    1871.    p.  349  et  seq. 

■"  See  Pfliiger  (Prof.  E.).  "  Neuritis  Optica."  Arch.  f.  Ophthal.,  Bd.  XXIV., 
Abth.  2,  1878,  p.  178. 

^  Thorowgood.  "  Case  of  optic  neuritis,  with  complete  loss  of  vision."  Clinical 
Transactions,  Vol.  VIII. ,  1875,  p.  80. 

*  Abadie.  "  De  I'atrophie  des  nerfs  optiques  dans  le  mal  du  Pott."  Bull,  de  la 
See.  de  Chir.,  Jan.  12, 1876. 

*  Gowers.    A  manual  and  atlas  of  medical  ophthalmosoopyi    1879.    p.  156. 


390  DISEASES   OF  THE 

Allbutt  in  transverse  myelitis  of  the  dorsal  region,  and  Erb^ 
reports  one  case,  and  Seguin^  two  cases,  of  transverse  myelitis 
associated  with,  double  optic  neuritis ;  while  Dreschfeld'  com- 
municates a  case  of  transverse  myelitis  of  the  cervical  region, 
and  a  case  of  acute  disseminated  myelitis,  in  both  of  which 
double  optic  neuritis  was  present,  and  without  any  change 
beyond  some  congestion  being  found  after  death  in  the  brain. 

A  third  group  of  cases  is  caused  by  morbid  conditions  of  the 
blood  and  consequent  abnormalities  of  nutrition.  The  affec- 
tions which  cause  optic  neuritis  are  severe  acute  diseases,  such 
as  typhus,  measles,  pneumonia,  puerperal  fever,  and  scarlet 
fever.  It  sometimes  occurs  after  exposure  to  severe  cold  or  to 
a  very  bright  light,  and  is  occasionally  produced  by  the  sudden 
suppression  of  the  menses  or  other  accustomed  discharge ;  or 
results  from  chronic  blood  poisoning  by  lead,  alcohol,  syphilis, 
diabetes  mellitus,  and,  above  all,  from  chronic  Bright's  disease. 

Double  optic  neuritis  is  occasionally  met  with  in  cases  which 
from  the  symptoms  must  be  regarded  as  undoubted  examples  of 
intracranial  disease,  and  yet  in  which  the  post-mortem  examina- 
tion does  not  reveal  any  disease  within  the  cranium.*  A  patient 
suffering  from  cancer  of  the  pylorus  complained  of  intense  head- 
ache, and  on  ophthalmoscopic  examination  I  discovered  double 
optic  neuritis,  with  a  moderate  degree  of  swelling  of  the  discs.  The 
eyes  were  subsequently  examined  by  Dr.  Little,  who  confirmed 
this  opinion.  Four  days  afterwards  the  patient  was  seized  with 
general  convulsions,  and  died  comatose  in  a  few  days.  It  was  fully 
expected  that  secondary  cancerous  deposits  would  be  found  in  the 
brain,  but  the  most  careful  examination  failed  to  discern  any  lesion 
beyond  a  considerable  degree  of  congestion  of  the  membranes. 

Varieties  of  Optic  Neuritis  and  Atrophy. 
Optic  neuritis  was  divided  by  Von  Graefe^  into  two  varieties. 

1  Erb  (W.).  "Ueber  das  Zusammenvorkommen  von  Neuritis  optica  und 
Myelitis  subacuta."    Arch.  f.  Psyehiat.,  Bd.  X.,  1879-80,  p.  146. 

^  Seguin.  Journal  of  Nervous  and  Mental  Diseases,  April,  1880.  Abstr.  Cen- 
tralbl.  f.  med.  Wissensch.,  Bd.  XVIII.,  1880,  p.  717. 

^  Dreschfeld  (J.).  "On  two  cases  of  acute  myelitis  associated  with  optic 
neuritis."    The  Lancet,  Vol.  I.,  1882,  pp.  8  and  52. 

"See  Jackson  (Hughlings).  "On  optic  neuritis  in  intracranial  disease,"  1881, 
p.  4.     Reprinted  from  the  Medical  Times  and  Gazette,  March  19,  1881. 

»  Graefe  (Von).  Arch.  f.  Ophth.,  Bd.  VII.,  1860,  Abth.  2,  p.  58;  and  Bd.  XII., 
Abth.  2,  p.  100. 


NERVES  OF  SPECIAL  SENSE.  391 

The  first  of  these  is  caused  by  extension  to  the  optic  disc  and 
retina  of  inflammatory  changes  occurring  in  the  optic  tracts  or 
nerves  within  the  cranium,  and  is  liamed  neuritis  descendens  or 
neuro-retinitis.  In  the  second  variety  the  inflammatory  changes 
are  limited  to  the  intraocular  termination  of  the  nerve,  and  when 
the  disc  is  swollen,  as  it  usually  is,  this  form  is  named  t?te 
engorged  or  choked  disc.  But  it  is  not  often  possible  to  distin- 
guish by  ophthalmoscopic  examination  alone  cases  of  descending 
neuritis  from  the  minor  degrees  of  the  engorged  disc,  and  con- 
sequently it  is  unnecessary  to  attempt  a  separate  description  of 
them.  The  optic  nerve  may  become  diseased  not  only  in  its 
intracranial  course,  but  also  in  its  passage  through  the  optic 
foramen  and  orbit.  Inflammation  of  the  nerve  in  its  extracranial 
course  may  begin  in  the  substance  of  the  nerve  or  in  its  sheath ; 
these  forms  being  named  retro-bulbar  neuritis  and  retro-hulbar 
perineuritis  respectively,  but  this  distinction  is  of  more  theo- 
retical than  practical  interest.  The  changes  which  occur  in  the 
retina  and  optic  nerve  in  Bright's  disease  are  so  important  to 
the  physician  as  to  demand  a  separate  description. 

The  optic  nerve  is  subject  to  various  forms  of  atrophy,  the 
most  practical  classification  of  them  being  that  which  divides 
them  into  primary  and  secondary  atrophy. 

The  diseases  of  the  optic  nerve  may  thus  be  divided  into  : — 

A.  Congestive  and  Inflammatory  Afeotions. 

(I.)  Simple  congestion  of  the  disc. 

(II.)  Congestion  with  swelling  of  the  disc  (optic  neuritis). 
(III.)  Albuminuric  retinitis,  and  neuritis. 

B.  Atrophic  Affections. 

(I.)  Simple  or  primary  atrophy. 
(II.)  Secondary  atrophy. 

(A)  INFLAMMATORY  AFFECTIONS  OF  THE  OPTIC  NERVE. 

(I.)  Simple  Congestion. — The  most  promment  symptom  of 
simple  congestion  is  increased  redness  of  the  disc.  The  increase 
in  the  intensity  of  the  red  colour  of  the  disc  is  more  readily  recog- 
nised when  it  is  greater  in  one  eye  than  in  the  other,  or  greater 
than  it  was  at  a  previous  examination.  The  redness  invades  the 
physiological  cup,  and  may  entirely  obscure  it ;  the  sclerotic  ring 


392  DISEASES   OF   THE 

and  edge  of  the  choroid  are  also  rendered  indistinct,  and  the  disc 
loses  its  sharpness  of  outline.  This  is  a  chronic  condition, 
and  Dr.  Gowers^  thinks  that  it  corresponds  to  that  described  by 
Dr.  Clifford  Allbutt^  under  the  name  of  "  chronic  neuritis." 

(II.)  Optic  Nevuritis. — In  this  condition  cedema  is  associated 
with  the  congestion.  The  normal  rosy  tint  of  the  disc  is  increased, 
its  edge  is  blurred,  and  there  is  a  pale  reflection  from  the  adja- 
cent retina,  which  surrounds  the  disc  with  an  indistinct  halo. 
The  central  cup  is  obscured;  there  is  often  distinct  swelling 
of  the  disc,  which  may  present  a  striated  appearance  at  its 
periphery,  and  the  edge  of  the  choroid  is  concealed.  In  the 
early  stage  of  the  affection  the  disc  is  red,  swollen,  and  cloudy; 
its  edge  is  veiled  so  that  it  cannot  be  seen  by  direct  examina- 
tion, and  as  the  process  increases  the  edge  of  the  disc  cannot  be 
seen  even  on  indirect  examination.  The  disc  is  swollen  and 
enlarged,  its  border  is  badly  defined  and  hazy,  and  in  advanced 
cases  its  position  can  only  be  ascertained  by  the  point  of  emer- 
gence of  the  vessels.  The  disc  assumes  a  reddish  grey  colour 
and  its  periphery  becomes  distinctly  striated,  partly  owing  to  the 
swelling  and  opacity  of  the  nerve  fibres,  and  partly  to  an  enor- 
mous development  of  minute  vessels.  The  veins  are  engorged, 
tortuous,  and  often  varicose,  while  the  arteries  are  more  or  less 
reduced  in  size,  and  appear  paler  than  the  veins.  When  exuda- 
tion takes  place,  the  vessels  become  veiled  and  lost  to  sight  at 
the  border  of  the  disc,  but  reappear  partially  as  they  proceed 
inwards,  and  again  disappear  before  reaching  the  lamina  cribrosa. 
Haemorrhages  not  unfrequently  occur  at  this  stage,  either  over 
the  swollen  disc  or  beyond  its  margin. 

The  inflammatory  process  may  now  subside ;  the  swelling 
gradually  diminishes,  the  edge  of  the  choroid  becomes  apparent, 
but  some  signs  of  the  previous  inflammation  generally  remain, 
such  as  a  narrow  zone  of  atrophy  adjacent  to  the  disc  and  along 
the  edge  of  the  choroid. 

(1)  Engorged  or  Choked  Disc. — If  the  inflammatory  process 
proceed  further,  the  tumour  formed  by  the  swollen  papilla  becomes 
much  more  prominent,  and  extends  laterally  in  all  directions ; 

1  Gowers  (W.  E.).  A  manual  and  atlas  of  medical  ophthalmoscopy.  Lond., 
1879.    p.  39. 

'^Allbutt.     Op.  cti.,  p.  64. 


Plate    1 


Whate  disc Atroplriy. 


GT?ey  disc  Atropliy. 


NERVES  OF  SPECIAL  SENSE.  393 

the  margins  of  the  swelling  become  steeper ;  and  consequently, 
as  the  vessels  pass  over  the  side,  they  become  concealed  by  the 
edge  of  the  swelling,  and  reappear  in  a  different  position  in  the 
fundus  {Plate  I.).  The  arteries  are  much  narrowed,  and  often 
invisible  over  the  swelling ;  the  veins  are  usually  visible  towards 
the  edge  of  the  tumour,  and  often  appear  distended  and 
tortuous  a  longr  distance  from  the  disc.  Haemorrhages  are  now 
frequent  and  extensive,  and  generally  appear  at  the  edge  rather 
than  on  the  surface  of  the  swelling.  Sight  usually  disappears 
rapidly  in  the  stage  of  strangulation.  This  form  of  optic 
neuritis  constitutes  the  choked  or  engorged  disc  (Allbutt). 

(2)  Subsidence  of  ITeuritis. — After  the  strangulation  has 
existed  for  some  time  the  venous  distension  gradually  lessens ; 
the  swelling  loses  its  intense  red  colour ;  hasmorrhages  cease ;  the 
extravasated  blood  disappears ;  and  the  tumour  lessens  in  height 
and  extent.  The  most  prominent  part  of  the  swelling  becomes 
pale,  and  this  central  pallor  extends  laterally  and  gradually 
invades  the  sloping  sides  of  the  tumour  and  the  adjacent  retina. 
The  centre  of  the  swelling  soon  presents  a  distinct  depression, 
and  the  vessels  become  more  and  more  constricted  owing  to  the 
cicatricial  contraction  of  the  newly-formed  connective  tissue. 
The  edges  of  the  choroid  and  sclerotic  now  become  dimly 
apparent,  and  the  disc  has  a  white  appearance,  but  does  not  for 
a  long  time  present  any  central  depression,  although  this 
appearance  may  be  ultimately  produced.  Although  the  disc  is 
white  at  first,  it  may,  on  reaching  the  retinal  level,  assume  a 
faint  grey  tint,  and  as  the  contraction  increases  this  tint  becomes 
more  and  more  marked.  The  edge  of  the  disc  is  often  irregular, 
and  surrounded  by  a  zone  of  choroidal  atrophy.  Retinal  haemor- 
rhages are  usually  absorbed  during  this  regressive  process,  but 
these  sometimes  become  transformed  into  spots  of  pigment,  or 
lead  to  the  formation  of  white  spots  on  the  retina. 

(3)  Descending  Neuritis  or  Neuro-Retinitis. — It  is  not  often 
possible  to  make  any  distinction  during  life  between  neuro- 
retinitis  and  the  slighter  degrees  of  engorged  disc.  In  neuro- 
retinitis  the  disc  presents  throughout  only  a  slight  degree  of 
swelling ;  the  changes  are  more  marked  towards  the  edge  than 
in  the  centre  of  the  disc ;  haemorrhages  are  absent ;  white  spots 
may  be  seen  scattered  over  the  disc  or  along  the  edges  of  the 


394  DISEASES   OF   THE 

vessels ;  and  the  atrophied  nerve  fibres  are  all  well  seen,  and  give 
to  the  disc  a  striated  appearance. 

(4)  Retro-hulbar  Neuritis  and  Perineuritis. — Retro-bulbar 
neuritis  is,  according  to  Dr.  Gowers,^  a  mixed  condition  of  con- 
gestion and  atrophy,  the  primary  stage  of  congestion  soon 
passing  on  to  atrophy  with  narrowed  vessels.  Optic  perineuritis 
is  the  result  of  chronic  inflammation  of  the  sheath  of  the  nerve, 
causing  thickening  and  purulent  infiltration  among  the  trabe- 
culse,  and  generally  ending  in  optic  neuritis.  This  form  has 
been  observed  in  periostitis  of  the  orbit,  and  in  constriction  of 
the  optic  nerves  from  thickening  of  the  cranial  bones.  It  is 
doubtful  whether  any  clinical  distinction  can  be  made  between 
optic  interstitial  neuritis  and  perineuritis. 

(III.)  Albuminuric  Retinitis. — In  diseases  of  the  kidneys  the 
arterioles  of  the  whole  body  undergo  changes,  in  which  the 
vessels  of  the  retina  participate.  The  first  retinal  change  to 
be  observed  consists  of  great  diminution  in  the  calibre  of  the 
arteries  as  compared  with  the  veins.  The  arteries  are  some- 
times observed  as  lines  only,  and  when  slight  swelling  of  the 
retina  is  present  they  may  be  invisible  beyond  the  edge  of 
the  disc.  In  a  more  advanced  stage  white  lines  are  seen  along 
the  edges  of  the  arteries,  partly  due  to  a  sclerosis  of  the  outer 
coat  and  partly  to  a  certain  degree  of  atrophy  of  the  retina. 
Irregular  dilatations  are  often  observed  in  the  retinal  capillaries, 
and  the  arteries  are  liable  to  aneurismal  dilatations.  Retinal 
hasmorrhages  form  a  marked  feature  of  even  the  early  changes 
which  take  place  in  Bright's  disease.  These  hseraorrhages  occur, 
according  to  Gowers,  in  the  nerve-fibre  layer;  they  often  follow 
the  course  of  the  vessels,  and  present  a  striated  appearance,  or 
are  flame-shaped  when  larger.  When  true  albuminuric  retinitis 
is  established  still  further  changes  are  observed  ;  these  are  com- 
bined in  such  various  ways  that  the  affection  may  be  divided 
into  the  following  varieties,  viz.  (1)  degenerative,  (2)  hsemor- 
rhagi^,  and  (3)  inflammatory  retinitis,  to  which  may  be  added 
(4)  albuminuric  neuritis  (Gowers). 

(1)  Degenerative  Albuminuric  Retinitis. — This  form,  which  is 
the  most  common,  begins  by  the  appearance  of  small  white  spots 
on  the  retina ;  they  are  small  and  rounded  at  first,  but  after  a 

^  Gowers.     Op.  cit,  p.  75. 


NERVES  OF   SPECIAL   SENSE.  395 

time  increase  in.  size,  become  irregular  in  outline,  and  neigh- 
bouring spots  sometimes  coalesce  to  form  large  white  patches. 
Small  white  spots  are  generally  to  be  seen  around  the  macula 
lutea ;  they  are  sometimes  so  small  as  to  be  only  visible  on 
carefol  direct  examination,  but  are  at  other  times  large  and  well- 
marked,  and  arranged  end  to  end,  so  as  to  form  radiating  streaks 
irregularly  disposed  around  the  macula  lutea,  and  giving  to  the 
retina  at  this  part  a  silvery  appearance.  Retinal  hsemorrhages 
may  be  present,  but  they  are  not  generally  well  marked  in  this 
variety,  and  the  optic  disc  does  not  undergo  very  conspicuous 
changes. 

(2)  Haemorrhagic  Albuminuric  Retinitis. — The  chief  charac- 
teristic of  this  variety  is  the  large  number  of  hsemorrhages 
which  occur ;  degenerative  changes  do  not  take  place  at  an  early 
period  of  the  affection,  although  in  the  later  stages  there  is  more 
or  less  of  degeneration  adjacent  to  the  hemorrhages,  and  white 
spots  are  then  usually  present  around  the  macula  lutea. 

(3)  Infiammatory  Albuminuric  Retinitis. — In  this  variety 
there  is  a  general  swelling  of  the  retina,  the  vessels,  especially 
the  arteries,  are  concealed,  and  the  disc  is  obscured.  The  veins 
are  distended  and  often  tortuous,  with  irregular  outline ;  the 
arteries  are  thready  and  numerous ;  large  hsemorrhages  often 
occur ;  and  the  white  spots  are  also  usually  numerous  and  well 
marked.  The  inflammation  may  occasionally,  although  very 
rarely,  subside,  and  then  evidences  of  degeneration  of  the  retina 
become  more  prominent,  and  the  optic  nerve  may  present  signs 
of  secondary  atrophy. 

(4)  Albuminuric  Neuritis. — In  this  variety  inflammation  of 
the  optic  nerve  predominates  over  the  retinal  changes ;  the  edges 
of  the  disc  are  indistinct  and  veiled  under  a  greyish  red  swelling ; 
the  arteries  are  small  and  often  hidden;  and  the  veins  even 
may  be  concealed  in  the  swelling,  and  form  curves  over  the 
sides  of  the  swollen  disc.  White  spots  may  be  seen  on  the 
surface  of  the  swollen  disc,  on  the  retina,  and  round  about  the 
macula  lutea,  while  small  hemorrhages  may  be  observed  about 
the  fundus,  but  are  rare  over  the  swollen  disc.  When  the  in- 
flammation subsides  a  consecutive  atrophy  of  the  optic  nerve 
may  be  left.  Albuminuric  neuritis  cannot  in  many  cases  be 
distinguished  from  ordinary  optic  neuritis  by  the  most  careful 


396  DISEASES   OF  THE 

ophthalmoscopic  examination.  It  must,  therefore,  be  remem- 
bered that  in  cases  where  albamen  is  found  in  the  urine,  along 
with  other  evidences  of  chronic  disease  of  the  kidneys,  the 
presence  of  double  optic  neuritis  loses  much  of  its  diagnostic 
significance  as  a  sign  of  intracranial  disease. 

General  Symptoms. — In  many  advanced  cases  of  optic 
neuritis,  even  in  the  choked  disc,  sight  is  quite  unimpaired,  and 
when  amblyopia  is  present  its  degree  is  by  no  means  propor- 
tional to  the  amount  of  changes  observed  on  ophthalmoscopic 
examination. 

In  retro-bulbar  neuritis,  on  the  other  hand,  a  high  degree  of 
unilateral  or  bilateral  amblyopia  may  precede  for  some  time  any 
ophthalmoscopic  appearances.  Vision  is  also  likely  to  fail  sooner 
in  descending  neuritis  than  in  cases  of  engorged  disc. 

In  all  severe  cases  of  optic  neuritis,  diminution  of  the  acute- 
ness  of  vision,  which  may  take  place  in  any  of  the  zones  of  the 
visual  field,  appears  after  a  longer  or  shorter  time.  The  point 
of  distinct  vision  is  at  times  eccentric ;  at  other  times  there  is 
general  or  partial  and  usually  irregular  contraction  of  the  visual 
field,  or  blind  spots  (scotomata)  may  appear  on  it.  At  times 
there  is  great  sensitiveness  to  light,  or  the  patient  complains  of 
subjective  sensations  of  vision,  such  as  sparks  or  flashes  of  light, 
and  coloured  spectra.  These  phenomena  may  occur  when  there 
is  complete  blindness.  The  patient  may  also  suffer  from  muscoe 
volitantes,  and  slight  pain  in  the  eyeball,  caused  either  by 
irritation  of  the  fifth  or  pressure  on  the  optic  nerve.  It  cannot, 
however,  be  too  strongly  emphasised  that  the  most  marked  optic 
neuritis  may  be  present,  without  any  recognisable  diminution  of 
the  acuteness  of  vision,  or  any  subjective  symptom  which  would 
lead  us  to  suspect  the  presence  of  changes  in  the  optic  discs  or 
retinae. 

The  cerebral  symptoms  most  likely  to  be  associated  with  optic 
neuritis  are  headache,  vertigo,  vomiting,  loss  of  memory,  unilateral 
epilepsy,  hemiplegia,  and  paralysis  of  some  or  all  of  the  ocular 
muscles. 

Morbid  Anatomy. — In  order  to  understand  the  mechanism 
by  which  the  swelling  of  the  disc  is  caused  in  optic  neuritis,  the 
anatomical  relations  of  the  nerve  must  be  kept  in  mind  (§  205). 
Inflammation  of  the  optic  nerve  is  accompanied  by  a  serous 


NERVES  OF   SPECIAL  SENSE.  397 

infiltration  which  augments  its  volume  and  diminishes  its  con- 
sistence.  The  sheath  of  the  nerve  is  often  distended  with  fluid, 
the  distension  being  greatest  a  short  distance  behind  the  eye. 
The  connective  tissue  of  the  pial  sheath  and  of  the  trabeculse 
surrounding  the  nerve  bundles  becomes  thickened,  and  manifests 
an  increase  of  nuclei  or  cells,  and  a  considerable  number  of 
leucocytes  may  be  observed  around  the  vessels.  A  like  increase 
of  nuclei  may  be  observed  between  the  nerve  fibres  themselves. 
The  nerve  fibres  become  irregularly  thickened,  and  present  a 
varicose  appearance,  while  the  medullary  sheath  becomes 
granular,  and  the  myeline  is  often  broken  up  into  globular 
masses.  In  advanced  cases,  the  tissue  of  the  lamina  cribrosa 
becomes  distended,  and  its  structure  greatly  altered.  The  veins 
are  large  and  tortuous,  while  the  arteries  are  abnormally  small 
and  often  quite  atrophied. 

The  first  explanation  of  the  conditions  observed  in  optic 
neuritis  was  attempted  by  Yon  Graefe.^  The  condition  which  he 
designated  as  descending  neuritis  was,  in  his  opinion,  caused  by 
inflammation  communicated  to  the  optic  nerve  from  inflamed 
meninges.  That  the  optic  nerve  is  liable  both  to  perineuritis 
and  to  descending  neuritis,  like  other  nerves,  is  not  seriously 
doubted  by  any  pathologist;  the  only  question  which  arises  is, 
whether  the  cases  described  by  Von  Graefe  as  descending  neuritis 
can  be  clinically  and  anatomically  distinguished  from  forms  of 
optic  neuritis,  which  arise  as  the  result  of  a  different  mechanism. 
The  cases  of  optic  neuritis  or  choked  disc,  which  occur  in  associa- 
tion with  cerebral  tumour,  and  in  which  there  is  no  evidence  of 
inflammation  in  the  trunks  of  the  optic  nerves,  Von  Graefe 
attributed  to  increase  of  intracranial  pressure,  obstructing  the 
return  of  blood  from  the  eye  by  compressing  the  cavernous  sinus, 
an  obstruction  which  would  be  greatly  intensified  by  the  un- 
yielding character  of  the  sclerotic  ring.  Against  this  theory  it 
may  be  urged  that,  on  the  one  hand,  large  tumour?  may  exist 
within  the  cavity  of  the  skull  without  giving  rise  to  any  optic 
neuritis,  while,  on  the  other,  cortical  tumours  so  small  that  they 
can  scarcely  be  supposed  to  increase  the  intracranial  pressure 
often  give  rise  to  the  most  marked  optic  neuritis.     It  was  also 

1  Graefe.     Arch.  f.  Ophthalmologie,  Bd.  VII.,  Abth.  2,  1860,  p.  2,  p.  58;  and 
Bd.  XII.,  Abth.  2,  1866,  p.  100. 


398  DISEASES   OF  THE 

shown  by  Sesemann^  that  the  supra-orbital  vein  anastomoses 
so  freely  with  the  facial  veins  that  pressure  on  the  cavernous 
sinus  would  not  produce  anything  beyond  a  temporary  effect. 
It  was  discovered  by  Schwalbe^  that  the  subvaginal  space 
around  the  optic  nerve  is  continuous  with  the  subdural  space 
around  the  brain;  and  Schmidt^  suggested  that  any  increase  of 
intracranial  pressure  would  tend  to  distend  the  sheath  of  the 
optic  nerve  with  fluid,  and  consequently  would  produce  strangu- 
lation of  the  nerve  fibres  in  their  passage  through  the  sclerotic 
ring  and  lamina  cribrosa.  Although  this  theory  is  very  largely 
accepted,  it  is  by  no  means  free  from  objections.  In  the  first 
place,  optic  neuritis  is  rarely  found  in  chronic  hydrocephalus, 
where  the  intracranial  pressure  is  very  great ;  while  the  affection 
may  be  present  in  an  intense  degree  in  the  case  of  a  small 
tumour,  where  the  increase  in  the  intracranial  pressure  must  be 
relatively  slight.  Whatever  part,  therefore,  increase  in  the  intra- 
cranial pressure  may  take  in  the  production  of  optic  neuritis,  it 
is  clear  that  some  other  factor  is  necessary  for  the  full  explanation 
of  the  mechanism  of  its  production.  This  factor  Dr.  Hughlings 
Jackson*  endeavoured  to  supply  by  suggesting  that  intracranial 
tumours  act  like  foreign  bodies,  and  produce  optic  neuritis  by 
their  irritating  effects.  This  theory  was  more  fully  elaborated  by 
Benedikt,^  who  gave  it  as  his  opinion  that  the  irritation  caused 
by  the  tumour  acted  on  the  optic  nerves  through  the  vaso-motor 
nerves,  and  it  is  now  known  as  the  hypothesis  of  reflex  vaso- 
motor action.  Dr.  Hughlings  Jackson^  now  maintains  that  optic 
neuritis  is  a  doubly  indirect  result  of  local  gross  organic  disease. 
He  supposes  that  the  local  growth  produces  an  irritation  of  a 
portion  of  the  cortex,  with  consequent  instability  of  grey  matter, 
which  induces  periodical  discharges  along  the  vaso-motor  nerves, 

1  Sesemami.  Du  Bois  Reymond's  Archiv.,  1869,  p.  lo4.  Abstr.  Centralbl.  f. 
med.  Wissensch.,  Bd.  VII,,  1869,  p,  574. 

*  Schwalbe,     Centralbl,  f .  med.  Wissensch.     1869,    p.  465. 

^Schmidt.  "Zur  Entstehung  der  Stanungspapille  bei  Hirnleiden."  Arch.  f. 
Ophthal.,  Ed.  XV.,  Abth.  2,  1869,  p.  193. 

*  Jackson  (Hughlings),  "Observations  on  defects  of  sight  in  brain  disease." 
Ophthalmic  Hospital  Reports,  Vol.  IV,,  1863-65,  pp.  30  and  389.  See  also  Mac- 
kenzie (Stephen),  "A  case  of  double  optic  neuritis,  without  gross  cerebral  lesion, 
with  remarks  on  the  immediate  causation  of  optic  neuritis."  Brain,  Vol,  II,,  1880, 
p,  257, 

^  Benedikt.    Elektrotherapie,     Wien,  1868,     p,  249  et  seq. 

^  Jackson  (Hughlings),  "  On  optic  neuritis  in  intracranial  disease,"  p.  25. 
Reprinted  from  Medical  Times  and  Gazette,  March  19,  1881. 


NERVES  OF  SPECIAL  SENSE.  399 

just  as  occurs  along  voluntary  motor  nerves  in  unilateral  epilepsy. 
The  primary  effect  of  these  discharges  is  to  contract  the  blood- 
vessels of  the  optic  nerves,  but  secondary  paralysis  of  the 
coats  of  the  vessels  supervenes,  just  as  occurs  in  voluntary 
muscles  subject  to  unilateral  spasm  from  intracranial  disease. 
He  believes  that  the  nutritive  change  which  constitutes  optic 
neuritis  is  caused  by  this  secondary  paralysis.  The  vaso-motor 
theory,  even  as  thus  interpreted,  does  not  appear  to  me  to  meet 
all  the  difficulties  of  the  case,  and  I  feel  therefore  induced  to 
advance  another  opinion  without  attaching  any  particular  im- 
portance to  it  except  as  a  more  or  less  plausible  supposition.  The 
relation  subsisting  between  the  ganglia  of  the  posterior  roots  of 
the  spinal  nerves  and  the  afferent  nerves  is  well  known.  The 
structure  of  the  external  geniculate  bodies  lends  countenance  to 
the  view  that  they  are  the  homologues  of  the  ganglia  of  the  roots, 
and  if  so  they  will  bear  a  similar  relation  to  the  nutrition  of  the 
optic  nerves  that  the  spinal  ganglia  do  to  the  sensory  spinal 
nerves.  Irritation  of  the  external  geniculate  bodies  may  there- 
fore be  supposed  to  give  rise  to  trophic  changes  in  the  optic 
nerves,  and  if  the  position  of  these  bodies  near  the  edge  of  the 
tentorium,  and  in  the  angle  formed  by  the  crura  and  corpora 
quadrigemina  with  the  posterior  lobes  of  the  cerebrum  be  taken 
into  account,  it  will  be  seen  that  irritation  would  be  very  liable 
to  be  produced  by  various  diseases  of  the  brain,  and  especially  by 
diseases,  like  tumour,  which  are  likely  to  cause  displacements  of 
the  relative  positions  of  the  different  parts  of  the  encephalon. 

Treatment — Idiopathic  optic  neuritis  must  be  treated  by 
active  antiphlogistic  measures.  Two  or  three  leeches  should  be 
applied  to  each  temple,  or  a  few  ounces  of  blood  may  be  removed 
from  the  temple  by  the  artificial  leech.  In  the  case  of  optic 
neuritis  from  cerebral  tumour  the  possibility  of  syphilis  must 
never  be  forgotten,  and  it  is  a  good  rule  to  administer  the  iodide 
of  potassium  in  all  cases  in  which  there  is  the  slightest  possibility 
that  this  disease  may  have  been  acquired.  The  iodide  should 
be  given  in  large  doses  to  begin  with,  and  the  dose  still  further 
increased  if  there  is  the  slightest  sign  of  improvement. 

(B)   ATROPHIC   AFFECTIONS   OF   THE   OPTIC   NEIIVES. 

Atrophy  of  the  Optic  iVer^'e.— Atrophy  of  the  optic  nerve  is 


400  DISEASES   OF   THE 

a  state  in  which  the  intraocular  extremity  of  the  nerve  becomes 
slowly  and  progressively  transformed  into  a  pure  white  or 
greyish-white  disc.  There  is  complete  cessation  of  the  capillary 
nutrition  of  the  nerve,  and  consequently  the  healthy  rosy  tint  of 
the  disc  disappears. 

(I.)  Simple  atrophy  is  frequently  associated  with  disease  of  the 
spinal  cord,  and  especially  with  locomotor  ataxy,  and  consequently 
Charcot  called  it  tabetic  amaurosis,  or  parenchymatous  atrophy. 
It  appears  at  various  epochs  in  the  course  of  the  disease.  Some- 
times it  is  preceded  by  the  lancinating  pains  in  the  inferior  ex- 
tremities, and  by  many  of  the  other  symptoms  of  the  disease ; 
while,  at  other  times,  the  optic  lesion  precedes  by  many  years  all 
the  other  symptoms.  As  this  affection  comes  on  without  any 
definite  cause,  it  may  also  be  called  prim,ary  atrophy. 

(II.)  Secondary  atrophy  of  the  optic  nerve  is  caused  in 
various  ways.  The  following  varieties  of  the  affection  may  be 
distinguished  : — 

(1)  Atrophy  hy  compression  of  the  fibres  of  the  Optic  Nerve. 
This  form  of  atrophy  may  be  caused  by  pressure  on  the  chiasma 
or  on  the  optic  nerves  in  any  part  of  their  course  through  the 
base  of  the  brain,  optic  foramen,  or  orbit.  It  is  often  preceded 
by  a  stage  in  which  the  disc  is  congested,  but  inasmuch  as  the 
ophthalmoscopic  appearances  presented  by  the  simple  and  con- 
gestive varieties  are  the  same  when  once  atrophy  is  established, 
the  two  forms  may  be  described  together.  Lesions  of  one  optic 
tract  cause  bilateral  symmetrical  hemiopia,  but  it  is  only  after 
some  years  that  slight  pallor  of  the  corresponding  halves  of  the 
disc  is  observed. 

Symptoms  :  Ophthalmoscopic  Appearances. — On  ophthal- 
moscopic examination  the  optic  disc  is  observed  to  have  under- 
gone very  marked  changes.  (See  Plate  I.)  The  disc  assumes  a 
pearly  white  colour  (white  atrophy),  occasionally  mixed  with  a 
slight  tinge  of  blue  or  of  grey  (grey  atrophy).  The  contour  of 
the  disc  is  sharply  defined,  but  its  outline  may  be  slightly 
irregular,  and  in  advanced  cases  it  often  becomes  oval  and  some- 
what reduced  in  size,  although  the  normal  size  and  round  form 
may  be  long  preserved  after  the  fullest  blanching.  The  central 
artery  and  vein  maintain  their  normal  volume  and  direction,  but 
the  lateral  branches  of  the  disc  are  in  great  part  atrophied. 


NERVES  OF  SPECIAL  SENSE.  401 

This  affection  is  usually  bilateral,  but  occasionally  it  may  be 
limited  for  many  years  to  one  eye,  and  become  only  slowly  com- 
municated to  the  other.  The  retina  remains  perfectly  trans- 
parent, and  preserves  its  normal  aspect,  the  disc  being  the  only 
part  of  the  fundus  which  presents  any  appreciable  change.  The 
pupil  is  usually  contracted  (myosis),  but  at  other  times  it 
assumes  an  irregular,  angular,  or  oval  form,  probably  caused  by 
atrophy  of  some  of  the  branches  of  the  ciliary  nerves.  The 
pupils  are  also  often  of  unequal  size. 

General  Symptoms. — The  onset  of  the  affection  is  usually 
slow,  and  the  patient  observes  for  months  or  years  that  his  sight 
is  becoming  gradually  and  progressively  enfeebled.  The  field  of 
vision  is  not  as  a  rule  diminished  at  first,  but  with  the  progress 
of  the  affection  it  becomes  concentrically  contracted.  Defect  in 
the  acuteness  of  vision  is  usually,  but  not  always,  in  direct  pro- 
portion to  the  degree  of  change  in  the  optic  nerve,  and  occa- 
sionally the  patient  can  read  the  finest  print  when  the  atrophy 
is  very  advanced,  and  when  there  is  concentric  diminution  of  the 
field  of  vision.  The  latter  may  be  altered  in  various  ways,  but 
concentric  limitation  is  the  most  frequent  change.  At  times  a 
central  scotoma  may  be  associated  with  concentric  restriction. 
This  form  of  alteration  generally  arises  from  toxic  causes,  such 
as  alcohol  atid  tobacco.  Loss  of  colour  vision  (achromatopsia)  is 
especially  well  marked  in  this  form  of  atrophy. 

Various  subjective  sensations  are  experienced,  such  as  sparks 
or  flashes  of  light  (photopsia),  or  a  subjective  play  of  colours  or 
coloured  spectra  (chromatopsia).  The  mode  of  locomotion  of 
these  patients  is  characteristic.  The  head  is  retracted  and  the 
chin  elevated,  the  gait  is  shuffling,  the  eyes  are  directed  upwards, 
and  the  expression  of  the  countenance  is  vague,  owing  to  the 
fact  that  the  eyes  are  not  fixed  on  any  object.  If  the  affection 
has  been  developed  slowly,  nystagmus  may  be  present. 

(2)  Atrophy  Secondary  to  Optic  Neuritis. — The  main  features 
of  this  form  of  atrophy  have  already  been  described,  when  the 
subsidence  of  neuritis  was  under  consideration.  The  disc  is  at 
first  yellow  or  dull  white,  its  contour  is  completely  hidden  under 
an  exudation,  and  the  vessels  are  varicose ;  as  the  exudation 
becomes  absorbed  the  nerve  becomes  whiter  and  whiter,  its 
capillaries  undergo  atrophy,  and  the  central  vessels  themselves 
VOL.  L  A  A 


402  DISEASES   OF  THE 

become  smaller  although  they  preserve  their  tortuous  course. 
The  disc  is  not  sharply  defined,  as  in  simple  atrophy,  but  its 
contour  is  irregular  and  broken,  and  its  edges  are  obscured  by 
exudation.  It  is  larger  than  normal,  and  white  patches  of  exuda- 
tion may  be  observed  in  its  vicinity  and  in  the  neighbourhood  of 
the  macula,  indicating  that  the  inflammation  had  previously 
spread  to  the  retina. 

Atrophy  secondary  to  optic  neuritis  is  not  always  followed  by 
blindness,  and  patients  who  had  completely  lost  their  sight 
during  the  acute  period  may  now  recover  some  degree  of  vision 
and  retain  it  for  the  remainder  of  life. 

(3)  Atrophy  Secondary  to  Obliteration  of  Vessels. — This  form 
of  atrophy  is  caused  by  embolus  or  thrombosis  of  the  central 
artery  of  the  retina.  The  disc  is  of  a  pearly  white  colour  without 
a  tinge  of  grey,  but  its  margin  is  usually  covered  with  a  white 
veil,  which  extends  to  the  retina.  The  arteries  are  so  small  as 
to  be  scarcely  appreciable,  and  are  often  surrounded  by  a  whitish 
and  more  or  less  opaque  exudation.  After  the  exudation  has  been 
absorbed,  this  form  of  atrophy  is  distinguished  from  every  other 
kind  by  the  small  size  of  the  arteries  of  the  disc  and  retina. 

(4)  Choroiditic  Atrophy. — Atrophy  of  the  disc  secondary  to 
choroido-retinitis  closely  resembles  that  which  results  from  oblite- 
ration of  the  central  artery  of  the  retina.  There  is  a  marked 
wasting  of  the  retinal  vessels  in  choroiditic  atrophy,  but  the  disc 
is  often  characterised  by  a  peculiar  reddish  or  yellowish  tint, 
and  its  edges  appear  slightly  blurred  (Gowers). 

(5)  Atrophy  Secondary  to  Retinitis  Pigrnentosa. — In  retinitis 
pigmentosa  the  retinae  becomes  studded  by  pigmentary  spots. 
This  migration  of  the  choroidal  pigment  into  the  retinae  is  accom- 
panied by  an  atrophy  of  the  central  vessels,  their  walls  becoming 
thickened,  and  their  calibre  much  diminished  in  size.  On  oph- 
thalmoscopic examination  the  central  vessels  appear  sensibly 
diminished  in  size,  and  their  collateral  branches  undergo  the 
same  alterations,  and  after  a  time  disappear  altogether.  The 
capillary  vessels  derived  from  the  ciliary  arteries  of  the  optic 
nerve  are,  however,  not  affected  to  the  same  extent ;  hence  the 
disc  generally  preserves  a  well  marked  rosy  tint. 

(6)  Atrophy  by  Excavation. — This  variety  of  atrophy  is 
caused  by  increased    intraocular  pressure   in    such    diseases  as 


NERVES   OF   SPECIAL   SENSE.  403 

glaucoma  and  hydrophthalmia,  and  it  is  characterised  by  the 
deep  excavation  of  the  optic  disc.  A  certain  amount  of  excava- 
tion may  take  place  in  the  later  stages  of  any  form  of  atrophy, 
owing  to  wasting  of  the  fibres  of  the  optic  nerve,  and  to  cica- 
tricial contraction  of  newly-formed  connective  tissue. 

§  212.  Morbid  Anatomy. — The  anatomical  changes  in  atrophy 
of  the  disc  extends  through  the  optic  nerves.  In  primary  atrophy 
the  nerve  is  much  reduced  in  size,  and  is  grey  and  gelatinous  in 
appearance.  The  connective  tissue  trabeculge  are  hypertrophied, 
and  the  nerve  fibres  themselves  are  progressively  destroyed. 
During  the  disappearance  of  the  medullary  sheath,  which  is  the 
first  to  underg^o  degeneration,  the  various  transformations  of 
myeline  already  described  in  the  case  of  other  nerves  may  be 
observed.  After  a  time  the  axis  cylinder  also  becomes  destroyed, 
and  the  nerve  becomes  changed  into  a  cord  of  connective  tissue. 
In  atrophy  from  pressure  the  nerve  is  much  reduced  in  size,  and 
there  is  great  increase  of  connective  tissue.  The  disc  usually 
presents  a  superficial  depression,  which,  according  to  Mliller,  does 
not  generally  pass  beyond  the  limits  of  the  choroid.  The  lamina 
cribrosa  does  not  generally  undergo  any  displacement,  and  it  is 
only  covered  by  a  thin  layer  of  the  debris  of  the  disc.  Mliller 
has  also  shown  that  the  ganglionic  layer  and  the  nerve  fibres  of 
the  retina  undergo  complete  atrophy,  while  the  other  layers  are 
unaffected.  The  degeneration  always  ascends  to  the  chiasma, 
and  the  optic  tracts  are  atrophied  in  long-standing  cases  as  far 
as  the  external  geniculate  bodies. 

§  213.  Course  and  Terminations. — The  progress  of  the  affec- 
tion is  usually  slow,  and  from  three  to  six  years  may  elapse 
before  complete  blindness  comes  on.  Syphilitic  atrophy  of  the 
optic  nerve  is  more  rapid  in  its  progress,  and  it  may  cause  blind- 
ness in  the  course  of  a  few  months.  The  atrophy  is  limited  at 
times  to  one  eye,  but  as  a  rule  it  is  binocular. 

§  214.  Prognosis. — Whatever  may  be  the  form  of  atrophy  of 
the  disc,  it  is  undoubtedly  one  of  the  gravest  affections  which 
can  affect  the  organ  of  vision.  In  progressive  atrophy  recovery 
is  almost  entirely  unknown.     A  temporary  improvement  may 


404  DISEASES   OF  THE 

at  times  be  obtained,  but  it  is  doubtful  how  far  this  is  due  to 
treatment,  inasmuch  as  the  functional  symptoms  may  remit 
slightly,  even  where  the  atrophic  process  is  steadily  progressive. 
The  prognosis  of  atrophy  secondary  to  optic  neuritis  is  more 
favourable.  The  cerebral  affection  which  has  caused  this  affec- 
tion may  be  capable  of  cure,  and  the  atrophy  may  become 
partial  and  cease  to  progress  further. 

Monocular  atrophy  of  the  disc,  provoked  by  a  local  cause, 
ocular  or  orbital,  is  less  grave ;  the  lesion  is  then  local,  and  the 
atrophy  remains  limited  to  a  single  eye,  while  the  sight  of  the 
other  is  preserved. 

§  215.  Treatment — The  treatment  of  atrophy  of  the  optic 
nerve  consists  in  removing  the  exciting  causes  of  the  affection, 
and  the  general  condition  of  which  it  is  a  symptom.  It  is 
necessary  to  inquire  whether  there  may  be  some  debilitating 
cause  for  the  disease,  such  as  exhausting  diarrhoea,  excessive 
menstrual  or  hsemorrhoidal  discharge,  and  sexual  or  any  other 
form  of  mental  or  physical  excess  calculated  to  engender  nervous 
debility.  An  inquiry  must  also  be  instituted  to  ascertain 
whether  the  disease  depends  upon  the  abuse  of  alcohol,  tobacco, 
or  other  toxic  agents. 

The  greatest  care  must  be  taken  to  ascertain  if  the  disease  is 
due  to  a  syphilitic  taint,  either  acting  primarily  on  the  nerve  or 
its  vessels,  or  secondarily  through  the  optic  neuritis  caused  by 
the  growth  of  a  gumma  within  the  cranium.  The  slightest 
suspicion  of  such  a  cause  must  be  promptly  followed  by 
appropriate  antisyphilitic  treatment.  Atrophy  from  scrofulous 
disease  of  the  brain  must  be  treated  by  iodide  of  iron  and  cod- 
liver  oil,  although  the  prognosis  in  this  case  is  not  so  favourable 
as  in  the  syphilitic  variety.  Nitrate  of  silver,  phosphorus,  and 
strychnia  have  each  been  found  useful  in  the  treatment  of  this 
affection,  the  first  of  them  being  probably  most  appropriate  for 
the  treatment  of  the  tabetic  variety.  Electrisation  of  the  eye  is 
occasionally  of  use  in  the  treatment  of  cases  in  which  vision  is 
not  completely  lost. 

(III.)— DISEASES  OF  THE  ACOUSTIC  NERVE. 

§  216.  Auditory  or  Acoustic  Hyperceathesia,  or  Hyperahuaia, 


NERVES   OF  SPECIAL  SENSE.  405 

is  that  condition  in  which  the  sensibility  of  the  auditory  sensory 
apparatus  is  abnormally  increased,  so  that  sounds  too  faint  to 
be  detected  in  the  normal  state  are  heard  distinctly,  while  the 
power  of  discriminating  differences  in  sounds  is  unusually  acute. 
Auditory  hypersesthesia  may  be  caused  by  an  affection  of  the  peri- 
pheral endings  of  the  auditory  nerve,  of  the  conductive  apparatus, 
or  of  the  cortical  acoustic  centre,  and  it  may  also  occur  as  a  symp- 
tom of  disease  of  the  accessory  apparatus  of  hearing.  Great 
differences  obtain  in  health  in  the  degree  of  acuteness  of  the 
sense  of  hearing  in  different  individuals  or  in  the  same  individual 
at  different  times.  Like  the  other  senses,  the  ear  is  capable  of 
being  educated ;  trained  musicians  can  detect  the  most  deli- 
cate shades  of  differences  in  tone,  and  it  is  a  matter  of  common 
observation  that  the  acuteness  of  hearing  is  greatly  increased  in 
the  blind.  Hyperakusia  is  often  observed  in  hysterical  patients 
and  in  conditions  of  ecstasy  and  sometimes  even  in  somnam- 
bulism. Auditory  hypersesthesia,  however,  generally  declares 
itself,  not  by  an  increased  power  of  discriminating  tones,  but  in 
an  increase  of  the  pleasant  or  painful  feelings  which  accompany 
sound.  This  condition  may  be  called  auditory  hyperalgesia.. 
The  painful  feelings  associated  with  sound  predominate  in 
disease.  Auditory  hyperalgesia  is  a  very  troublesome  symptom 
in  many  cases  of  acute  disease,  general  debility,  hysteria,  and 
various  mental  affections,  so  that  the  slightest  sound  is  exceed- 
ingly painful  to  the  patient. 

Auditory  hypereestliesia  occurs  in  peripheral  facial  paralysis  from  the 
increased  tension  of  the  tympanic  membrane,  which  results  from  paralysis 
of  the  stapedius  muscle. 

The  condition  in  which  the  sensation  of  hearing  is  accompanied  by 
painful  feehngs  must  be  carefully  distinguished  from  auditory  neuralgia  or 
otalgia,  which  most  probably  depends  upon  neuralgia  of  filaments  of  the 
inferior  maxillary  branch  of  the  trigeminus. 

§  217.  Concomitant  Symptoms. — Acoustic  hypersesthesia  is 
often  accompanied  by  auditory  subjective  sensations,  illusions, 
and  hallucinations.  Tinnitus  is  the  most  common  form  of  sub- 
jective sensation,  and  it  may  assume  the  forms  of  clanging, 
humming,  whizzing,  whistling,  and  other  noises.  This  condition 
is  seldom  of  nervous  origin.  It  is  generally  a  symptom  of  the 
most  different  diseases  of  the  external  or  middle  ear.     Tinnitus 


406  DISEASES   OF   THE 

is  sometimes  a  symptom  of  congestion  of  the  head,  and  occurs 
in  association  with  dizziness  in  Meniere's  disease  as  well  as  in 
anaemia  and  chlorosis,  and  after  great  loss  of  blood  and  the  use 
of  large  doses  of  quinine,  or  salicine. 

The  galvanic  ciirrent  affords  valuable  aid  in  the  diagnosis  of  the  various 
conditions  of  the  auditory  nerve.  The  method  of  examination  consists  of 
applying  one  pole  to  the  previously  moistened  auditory  meatus  (internal 
method),  or  to  the  tragus  of  the  ear  (external  method  of  galvanisation),  and 
the  other  pole  to  the  back  of  the  neck.  In  registering  the  results  obtained 
the  usual  symbols  are  employed  for  the  anode,  cathode,  and  for  the  closing 
and  opening  of  the  circuit.  In  addition  D  is  taken  to  mean  a  permanent 
action  of  the  pole,  and,  to  follow  the  German  notation,  Pf  represents 
whistling,  Kl  ringing,  Br  humming,  and  S  hissing  sounds.  Several  other 
symbols  are  introduced  to  indicate  modifications  of  these  sounds  ;  for 
example,  kl,  Kl,  Kl ',  and  Kl"  represent  respectively  a  faint,  moderate,  loud, 
and  very  loud  ringing  sound,  while  Kl  oo  represents  a  continuous,  and  Kl  > 
a  gradually  disappearing  ringing  sound.  Under  normal  conditions  the 
auditory  nerve  reacts  to  the  galvanic  current  according  to  the  following 
formula  : — 

Ca  S  Kl  Distinct  ringing  sound. 

Ca  D  Kl> Ringing  sound  gradually  disappearing. 

Ca  0 —  No  sound. 

An  S —  „ 

AnD— „ 

An  0  kl  Feeble  and  short  ringing  soimd. 

The  following  abnormal  reactions  may  be  obtained  : — 

(1)  Simple  Hypercesthesia. — In  hypereesthesia  the  nerve  reacts  to  a 
feebler  current  than  normal,  or  stronger  reactions  are  obtained  to  the  same 
current.     The  following  is  the  formula  to  a  moderate  ciu-rent: — 

Ca  S  KF    Very  loud  ringing  sound. 

Ca  D  Kl  00 Continuous  soimd  so  long  as  the  current  is  closed. 

Ca  0  — No  soimd. 

An  S  — No  sound. 

AnD — No  sound. 

An  0  Kl  >    ...  Loud  ringing  sound  gradually  disappearing. 

(2)  Simple  hypersesthesia  with  paradoxical  formula  in  the  ear  not 
experimented  upon  : — 

Galvanised  Eae.  Non-Galvanised  Eau. 

Ca  S  KF    . . .  Very  loud  ringing  sounds    — 

Ca  D  cx)   Continuous  sounds  — 

Ca  0  — No  reaction    Kl  > 

An  S  — No  reaction    Kl' 

An  D  — No  reaction    Kl  oo 

AnOKl>...  Loud  soimd  gradually  disappearing  ...     — 


NEEVES   OF   SPECIAL   SENSE.  407 

(3)  Hypersesthesia  with  anomalies  or  inversion  of  the  normal  formula. 
In  this  condition  reactions  are  obtained  first  to  continuous  application  of 
the  anode  (An  D),  then  to  anodal  closm-e  (An  S),  and  lastly  to  cathodal 
opening  (Ca  0),  none  of  them  being  obtained  in  health.  These  new 
sounds  also  differ  from  the  normal  sounds  in  timbre  and  pitch.  The 
following  examples  are  given  by  Erb  : — 

10  Elements  :  An  S  Br 

AnDBr> 
AnOpf> 

The  following  is  the  formula  for  complete  inversion  of  the  normal 
reactions : — 

6  Elem.:  Ca  S  —  6  Elem.:  AnS  Pf ' 

Ca  D—  AnD  Pf  od 

Ca  S  pf  >  AnO  — 

The  following  formulse  represent,  according  to  Hagen,i  the  various 
stages  of  hyper Eesthesia  until  complete  inversion  of  the  normal  formula  is 
reached : — 


10  Elements  :  Ca  S  Pf 
Ca  D  Pf  00 
CaObr' 


CaS    ... 

...  Kl" 

El' 

Kl' 

Kl 

kl 

— 

CaD   ... 

...  Kloo 

Kloo 

Kloo 

Kl> 

kl 

— 

CaO   ... 

...     — 

— 

s 

s 

s' 

s> 

AnS   ... 

...     — 

S 

S' 

S' 

S' 

S" 

AnD  ... 

...     — 

s> 

S> 

Soo 

Soo 

Soo 

AnO  ... 

...  kl> 

kl> 

kl' 

kl 

— 

— 

(4)  Qualitative  Anoraalies  of  the  galvanic  auditory  reaction  vntJiout 
hypercedhesia. — The  formulee  for  this  kind  of  reaction  are  as  numerous  as 
for  the  reactions  obtained  in  hypereesthesia,  only  stronger  currents  are 
required  to  evoke  them. 

(5)  Torpidity  of  the  Aihditory  Nerve. — In  such  cases  feeble  reactions  are 
obtained  only  by  the  use  of  strong  cmTents. 

Auditory  illusions  are  frequently  observed  in  mental  diseases, 
probably  not  so  often  as  illusions  of  sight,  but  frequently  in 
association  with  the  latter.  Hallucinations  of  hearing  some- 
times constitute  the  aura  of  an  epileptic  attack.  In  a  case  of 
traumatic  epilepsy,  under  my  care  at  present,  the  convulsive 
seizure  is  preceded  by  loud  noises  in  the  ears.  The  attacks  came 
on  for  the  first  time,  some  months  ago,  after  a  blow  received  by 
the  patient  an  inch  above  the  right  ear,  and  consequently 
opposite  to  the  superior  temporo-sphenoidal  convolution, 

'  See  Erb  (W.).  "The  galvanic  reactioBS  of  the  nervous  apparatus  of  hearing, 
in  conditions  of  health  and  disease."  Archives  of  Ophth.  and  Otology,  Vol.  I., 
No.  1,  New  York,  1869,  p.  232 ;  and  Ziemssen's  Handbuch  der  Allgemeinen 
Therapie.     Handbuch  der  Electrotherapie,  1  Half  te,  Leipzig,  18S2,  p.  22(5  et  seq. 


408  DISEASES  OF  THE 

The  illusions  depend  on  irritation  of  the  central  acoustic  organ.  Audi- 
tory illusions  are  most  frequently  obsert'ed  in  melancholia  and  dementia. 
In  the  former  the  illusions  assume  the  form  of  abusive  or  threatening  words, 
or  commands  to  do  acts  of  violence ;  in  the  latter  they  take  the  form  of 
heavenly  messages  of  revelations.  Such  phenomena  are  not  unfrequently 
associated  with  complete  deafness.  Auditory  illusions  are  sometimes  uni- 
lateral ;  in  some  cases  there  are  alternating  illusions  of  different  senses, 
such  as  right-sided  optic  and  left-sided  auditory  illusions. 

§  218,  Auditory  Anwsthe&ia  consists  of  abnormal  diminution 
or  abolition  of  the  sense  of  hearing.  The  cause  of  the  affection 
may  be  either  lesion  of  the  peripheral  end-organ  of  the  aiiditory 
apparatus,  of  the  conduction  apparatus,  or  of  the  central 
terminal  organ.  Dulness  of  hearing  or  complete  deafness  may 
occur  after  various  injuries  to  the  head,  such  as  fracture  of  the 
base  of  the  skull,  severe  concussions,  or  a  fall  on  the  back 
of  the  head.  It  is  a  symptom  of  circumscribed  affections  of 
the  cerebellum,  and  of  the  middle  and  posterior  lobes  of  the 
cerebrum ;  it  is  also  caused  by  cerebro-spinal  and  basal  meningitis, 
and  is  a  frequent  sequel  of  acute  infectious  diseases,  such  as  scarlet 
fever,  measles,  and  typhus.  Deafness  is  observed  in  hysteria, 
and  after  toxic  doses  of  quinine,  lead,  and  other  agents.  The 
consideration  of  the  pathology  of  these  conditions  must  be 
deferred  for  the  present. 

Deaf  mutism  is  often  a  congenital  affection,  and  then  frequently 
depends  on  arrest  of  development  of  the  internal  or  middle  ear, 
or  it  may  be  acquired  in  infancy. 

Treatment. — The  treatment  of  acoustic  hypersesthesia  and 
ansesthesia  has  not  been  attended  by  great  success.  Acoustic 
hypersesthesia  is  sometimes  improved  by  galvanisation,  mode- 
rately strong  currents  being  employed.  Duchenne  obtained 
good  results  in  nervous  deafness  from  the  use  of  the  faradic 
current. 

§  219.   Meniere's  Disease  (Aural  or  LahyrinthiTie 

Vertigo). 

Definition. — Meniere's  disease  is  characterised  by  attacks  of 
vertigo  associated  with  noises  in  one  or  both  ears  and  partial 
deafness. 


NERVES    OF    SPECIAL    SEXSE.  409 

Etiology. — The  disease  as  described  by  Me'niere^  comes  on 
suddenly  and  without  apparent  cause.  But  severe  vertigo  some- 
times accompanies  acute  and  ehroaic  catarrh  of  the  middle  ear, 
the  latter  affection  beiug  caused  chiefly  by  exposure  to  cold,  ox 
remaining  as  a  sequel  of  one  of  the  acute  specific  fevers.  Deaf- 
ness, with  vertiginous  attacks,  may  be  produced  by  severe  fever, 
erysipelas,  eczematous  eruptions  on  the  head,  mumps,  angina 
Ludovici,  or  sunstroke,  in  the  absence  of  any  disease  of  the  middle 
ear,  and  it  is  probable  that  in  these  cases  the  disease  is  caused  by 
inflammation  of  the  labyrinth.-  Slight  and  transient  vertigo  may 
also  be  produced  by  the  impulsion  of  air  or  fluids  through  the 
Eustachian  tube  into  the  tympanic  cavity,^  by  external  pressure 
on  the  drum-head  by  wax  or  other  accumulations  in  the  meatus,^ 
or  by  the  passage  of  a  galvanic  current  through  the  ears. 

§  220.  Syniptoms. — The  characteristic  symptoms  of  Meniere's 
disease  are  sometimes  preceded  by  partial  deafness,  earache,  and 
other  indications  of  a  local  lesion  of  the  peripheral  organ  of  hearing. 
In  other  cases  the  patient  is  suddenly  attacked  with  deafness, 
noises  in  the  ears,  and  a  feeling  of  giddiness,  which  is  attended 
b}''  fainting,  nausea,  and  vomiting.  The  attack  passes  off  in 
a  few  seconds  or  minutes,  but  recurs  after  a  variable  period,  the 
paroxysms  becoming  more  aggravated,  and  more  frequently 
repeated  as  the  disease  advances.  The  noise  is  sometimes  heard 
in  both  ears,  but  is  probably  always  more  pronounced  on  one 
side  than  the  other.  It  is  sometimes  compared  to  the  loud 
whistling  of  a  steam  engine,  at  other  times  to  a  succession  of 
explosions,  and  it  is  often  described  as  a  continuous  humming  or 
buzzing.  In  recent  or  shght  cases  the  noises  in  the  ear  cease 
with  the  attack  of  vertigo,  but  in  aggravated  forms  of  the  affec- 
tion they  continue  to  distress  the  patient  during  the  intervals. 

The  attack  of  vertigo  varies  in  duration  and   intensity.     In 

•Meniere  (Paxil).  Gaz.  me'd.  de  Paris,  1S61.  pp.  29.  55.  SS.  239,  379.  and  597. 
See  Synopsis  of  Meniere's  cases.  Knapp.  Arcliives  of  OphtL  and  Otoloar,  Vol. 
11. ,  Xo.  1,  1S71,  p.  229. 

-  Knapp  (K.).  "  A  cKnical  analysis  of  the  inflammatorT  affections  of  the  inner 
ear."    Archives  of  Ophthalmology  and  Otology,  Vol.  11. ,  Xo.  I.,  iS71,  p.  27S. 

^  Brunner  \G.).  '"On  vertigo  oecarring  in  affections  of  the  eai'."'  Axch.  f. 
Ophth.  and  Otology,  ToL  II.,  Xo.  1.  1S71.  p.  291. 

*  Toynbee.  ''Cerebral  affections  occuning  in  certain  ear  affections."  St. 
George's  Hosp.  Keports,  Vol.  I,,  186(5,  p.  117. 


410  DISEASES   OF   THE 

slight  cases  it  consists  of  a  momentary  feeling  of  swimming  in 
the  head  ;  in  severe  cases  each  pai'oxysm  may  extend  over  a 
period  of  ten  or  more  minutes ;  while  in  still  more  aggravated 
cases  the  feeling  of  uncertainty  and  giddiness  is  never  absent 
during  waking  hours,  and  every  effort  on  the  part  of  the  patient 
to  assume  the  erect  posture  determines  the  vertigo  along  with 
nausea  and  vomiting.  During  the  paroxysm  the  patient  feels 
as  if  he  were  falling  forwards,  backwards,  or  laterally,  or  were 
rotating  round  a  vertical  or  horizontal  axis ;  he  staggers  and 
clutches  at  surrounding  objects  for  support,^  or  actually  falls  in  a 
direction  corresponding  with  his  sensations.  The  patient  also  feels 
faint ;  the  skin  becomes  pallid,  cold,  and  covered  with  sweat ; 
the  pulse  is  feeble  and  flickering ;  and  there  is  an  intense  feeling 
of  nausea,  which  often  terminates  in  vomitinsr,  and  then  the 
attack  usually  comes  to  an  end.  Actual  syncope  may  occasionally 
occur,  and  there  may  be  transitory  loss  of  consciousness,  but  this 
is  exceptional.  The  patient,  however,  during  the  paroxysm  suffers 
from  confusion  of  ideas,  and  in  the  worst  cases  any  unusual  in- 
tellectual effort  may  determine  an  attack  of  vertigo. 

Oscillatory  movements  of  the  eyeballs  have  been  observed  by 
Schwabach  and  Hughlings-Jackson  during  the  attack.  In  the 
case  observed  by  Schwabach,^  the  eyes  were  turned  towards  the 
affected  side  and  slightly  downwards,  and  in  the  one  observed 
by  Hughlings-Jackson,^  "  each  eye  was  partially  and  very  slightly 
rotated  to  the  right  in  frequent  jerks  from  left  to  right,"  the  left  ear 
being  the  diseased  one.  During  the  attacks  there  was  in  both  cases 
an  apparent  displacement  of  objects  with  reference  to  the  patient ; 
in  the  case  described  by  Hughlings-Jackson,  objects  wei^e  said 
to  revolve,  contrary  to  what  might  have  been  expected,  from  left 
to  right,  or  in  the  same  direction  as  the  rotation  of  the  eyes.  An 
instructive  case  of  this  disease  is  recorded  by  Mr.  Lewis  Mackenzie 
and  quoted  by  Hughlings-Jackson,  in  which  the  patient  —  a 
medical  man — was  much  distressed  by  continuous  noises  in  the 
right  ear,  following  the  discharge  of  a  heavily-loaded  gun  near 
it,  and,  along  with  the  other  more  usual  symptoms  of  auditory 

'  Charcot  (J.-M.).  Lemons  sue  les  Maladies  du  Systeme  Nerveux.  Tome  II., 
1877,  p.  318. 

*  Schwabach.  Zeitschr.  f.  pract.  med.,  1878,  No.  11.  Abstr.  Canstatt's  Jahresb., 
Vol.  II.,  1878,  p.  487. 

*  Jackson  (Hughlings).     Brain.    Vol.  III.,  1879-80,  p.  29. 


NERVES   OF   SPECIAL   SENSE,  411 

vertigo,  there  was  manifested  a  constant  tendency  to  walk  to 
the  left.  It  was  shown  by  Hinton^  that  the  perception  of  musical 
notes  is  faulty  in  many  cases  of  this  disease ;  in  one  case  observed 
by  him,  g  of  the  third  octave  was  heard  as  c  of  the  octave  below, 
or  twelve  notes  lower,  and  more  or  less  similar  results  were 
obtained  with  other  notes. 

§  221.  Course,  Duration,  and  Terminations. — The  paroxysms 
of  vertigo  come  on  at  first  at  irregular  intervals ;  they  increase 
gradually  in  frequency  and  intensity,  and  in  aggravated  cases 
the  patient  suffers  continuously  from  some  degree  of  vertigo, 
while  he  is  liable  to  paroxysmal  exacerbations  of  great  severity. 
The  noises  in  the  ears  may  cease  at  first  during  the  intervals, 
but  after  a  time  become  constant.  The  sense  of  hearing  becomes 
gradually  diminished,  and  ultimately  complete  deafness  of  the 
affected  ear  is  established,  when,  fortunately,  the  paroxysms  of 
vertigo  and  all  the  distressing  symptoms  of  the  disease  cease. 

Morbid  Anatomy  and  Physiology. — With  regard  to  the 
situation  of  the  lesion  Meniere  and  others  appear  to  think  that 
it  is  limited  to  the  semicircular  canals  and  the  vestibule, 
but  Knapp  believes  that  all  parts  of  the  labyrinth  are  involved. 
The  disease  may  be  primary  or  secondary  to  affections  of  the 
tympanum  and  cranial  cavity.  The  primary  affections  of  the 
labyrinth  are  supposed  by  Knapp  to  be  caused  by  (1)  haemor- 
rhage,  (2)  serous  exudation,  and  (3)  the  formation  of  pus.  The 
case  of  a  girl  is  reported  by  Meniere,  who  caught  cold  whilst 
menstruating ;  she  suddenly  became  deaf,  suffered  from  vertigo 
and  vomiting,  and  died  on  the  fifth  day.  The  brain  and  spinal 
cord  were  everywhere  healthy,  and  the  only  disease  found  was  a 
sanguineous  exudation  in  the  semicircular  canals  and  vestibule 
on  both  sides.  If  deafness  occur  suddenly  in  a  previously 
healthy  person  with  apoplectiform  symptoms,  and  the  latter 
symptoms  rapidly  disappear  while  the  deafness  remains,  Knapp'^ 
believes  that  we  may  infer  that  the  lesion  is  a  haemorrhage  or 
serous  effusion  into  the  cavity  of  the  labyrinth.  He,  how- 
ever, thinks  that  the  presence  of  deafness  for  certain  musical 

^  Hinton  (J.^.    "  On  Labyrinthine  Vertigo ;  sometimes  called  Meniere's  Disease." 
Guy's  Hospital  Keports,  Third  Series,  Vol.  XVIIL,  1873,  p.  198. 
^  Knapp.     Loc.  cit.,  p.  235. 


412  DISEASES   OF  THE 

sounds  in  Meniere's  disease  is  a  positive  proof  that  the  disease  is 
neither  limited  to  the  acoustic  nerve  outside  the  labyrinth,  nor  to 
the  semicircular  canal  and  vestibule,  but  that  it  extends  to  the 
cochlea.  Injuries  of  the  head  are  sometimes  followed  by  sudden 
deafness  and  the  other  symptoms  of  aural  vertigo.  In  these  cases 
the  symptoms  may  be  caused  by  haemorrhage  or  effusion  into  the 
labyrinth  without  fracture,  but  more  frequently  there  is  fracture 
of  the  petrous  portion  of  the  temporal  bone,  followed  by  haemor- 
rhage and  inflammation  in  the  membranous  labyrinth.  Disease 
of  the  labyrinth  may  be  set  up  by  extension  of  inflammation 
from  the-  middle  ear  in  cases  of  acute  and  chronic  catarrh  of 
the  latter,  and  a  purulent  otitis  interna  is  met  with  as  a  com- 
plication of  purulent  meningitis.  The  deafness  which  follows 
fevers  and  other  affections  in  the  absence  of  disease  of  the  middle 
ear  is  most  likely  to  be  caused  by  serous  or  hsemorrhagic  inflam- 
mation in  the  labyrinth.  The  symptoms  of  aural  vertigo  are 
sometimes  associated  with  locomotor  ataxia,  a  case  of  this  kind 
being  recorded  by  Althaus.^  He  believes  that  the  aural  symptoms 
were  caused  by  a  neuritis  of  the  auditory  nerve,  corresponding  to 
the  neuritis  of  the  optic  nerve  which  leads  to  tabetic  amaurosis. 

The  most  consistent  theory  of  the  functions  of  the  semicircular 
canals  is  that  they  are  peripheral  end-organs  of  afferent  nerve 
fibres,  whose  central  end-organ  is  a  ganglion  by  means  of  which 
the  body  is  adjusted  to  the  objects  which  surround  us  in  space. 
Disease  of  the  peripheral  organs  leads  to  disorders  of  the  whole 
nervous  meclianism,  and  consequently  to  failure  in  the  preserva- 
tion of  finely-balanced  attitudes,  or  attitudes  requiring  for  their 
maintenance  numerous  and  delicately  co-ordinated  muscular  con- 
tractions. Vertigo  is  the  subjective  correlative  of  this  muscular 
inco-ordination.  This  disorder  of  equilibration,  as  it  is  called,  is 
attended  by  a  displacement  of  the  body  as  a  whole,  or  of  various 
parts  of  it,  such  as  the  eyes,  with  reference  to  surrounding  objects, 
the  subjective  correlative  of  this  objective  fact  being  that  the 
patient  feels  surrounding  objects  undergoing  a  displacement  in. 
reference  to  his  body.  According  to  this  theory  it  is  wrong  to 
speak  of  a  sense  of  equilibrium;  there  is  no  such  sense  apart 
from  the  various  forms  of  muscular,  cutaneous,  articular,  and 

•  Althaus  (J.).  The  American  Journal  of  the  Medical  Sciences.  Vol,  LXXVII., 
1879,  p.  371. 


NERVES  OF  SPECIAL  SENSE.  413 

osseous  sensibilities.  The  nervous  mechanism  by  which  our 
attitudes  in  space  are  chiefly  maintained  produces  corrections  of 
those  attitudes  in  an  unconscious  manner,  and  it  is  only  whilst 
the  adjustment  is  being  effected  that  the  mind  becomes  conscious 
of  the  action. 

§  222.  Diagnosis  and  Prognosis. — Auditory  vertigo  is  liable 
to  be  mistaken  for  the  vertigo  associated  with  gastric  disease  or 
sexual  excess,  the  diagnosis  being  rendered  more  difficult  by  the 
fact  that  a  considerable  degree  of  deafness  and  noises  in  the  ears 
may  be  present  in  the  latter.  It  is,  indeed,  believed  by  Woakes^ 
that  stomachic  vertigo  results  from  disturbances  of  the  circula- 
tion of  the  labyrinth  caused  by  irritation  of  the  inferior  ganglion 
of  the  cervical  sympathetic.  The  nutrient  artery  of  the  labyrinth 
is  a  branch  of  the  vertebral  artery ;  this  vessel  derives  a  rich 
plexus  of  nerves  from  the  inferior  cervical  ganglion,  which  also 
is  intimately  connected  with  the  stomach  and  heart,  so  that 
disorders  of  any  one  of  these  organs  is  very  liable  to  disturb  the 
functions  of  the  others.  In  true  auditory  vertigo  the  noises  are 
unilateral,  the  feeling  of  vertigo  is  very  intense,  and  is  accom- 
panied by  a  sensation  as  if  the  body  had  undergone  actual  dis- 
placement ;  these  symptoms  never  occur  to  the  same  degree  in 
the  vertigo  of  dyspepsia  or  sexual  excess.  Paroxysms  of  auditory 
vertigo  may  be  mistaken  for  epileptic  attacks,  and  can  only  be 
distinguished  by  a  careful  examination  of  the  symptoms,  the 
main  reliance  being  placed  upon  whether  the  attack  is  or  is  not 
attended  by  loss  of  consciousness.  Disease  of  the  cerebellum, 
locomotor  ataxia  attended  by  deafness,  and  sclerosis  in  patches, 
are  other  affections  which  may  at  times  be  mistaken  for  aural 
vertigo,  but  the  diagnostic  signs  between  them  will  be  subse- 
quently considered.  The  prognosis  is  grave  so  far  as  ultimate 
recovery  is  concerned,  but  the  symptoms  disappear  when  com- 
plete deafness  is  established. 

Treatment — If  the  symptoms  depend  upon  disease  of  the 
external  or  middle  ear,  the  patient  should  be  placed  under  the 
care  of  the  specialist,  and  when  the  local  disease  is  not  acces- 
sible to  treatment,  relief  may  be  obtained  by  rest  in  the  recum- 

'  Woakes  (S.).  "The  connection  between  the  stomachic  and  labyrinthine  ver- 
tigo."   British  MedicalJournal,  Vol.  I.,  1878. 


414  DISEASES   OF   THE 

bent  position.  The  administration  of  quinine  in  doses  of  from 
10 — 12  grains  appears  to  have  produced  great  amelioration  of 
the  symptoms  in  some  cases.  At  first  the  subjective  sounds 
caused  by  the  quinine  are  superadded  to  those  of  the  disease, 
and  the  symptoms  are  intensified,  but  if  the  quinine  be  omitted 
for  eight  or  ten  days  the  sounds  and  the  vertigo  undergo  notable 
diminution.  If  the  quinine  be  readministered  for  a  period  of 
from  eight  to  ten  days  the  symptoms  are  again  aggravated,  but 
not  so  much  as  at  first.  During  the  second  cessation  the  symp- 
toms undergo  further  amelioration,  which  may  go  on  to  complete 
arrest  of  the  vertiginous  attacks.-^  Cases  of  the  disease  have  been 
benefited  by  large  doses  of  salicylate  of  soda. 

§  223.  Otitis  acuta  intima  sive  Lahyrinthica  (VoltoUni's 

Disease). 

Definition. — An  affection  which  occurs  in  children ;  it  begins 
suddenly  with  acute  cerebral  symptoms  like  those  of  meningitis, 
and  when  these  abate  it  is  found  that  the  patient  is  rendered 
permanently  deaf. 

Etiology. — Little  is  known  with  regard  to  the  etiology  of  this 
affection  further  than  that  it  almost  exclusively  affects  children. 
Exposure  to  cold,  and  moist  dwellings,  may  probably  act  as  exciting 
causes.  It  is  found  associated  with  cerebro-spinal  meningitis,  and 
many  authorities  believe  that  the  affection  of  the  internal  ear  is 
always  secondary  to  a  meningitis. 

Symjptoins. — The  child  is  seized  with  a  sudden  and  often 
unaccountable  illness,  and  in  the  course  of  half  a  day,  or  a 
few  days  at  most,  cerebral  symptoms  become  prominent.  Older 
children  may  complain  of  shooting  pains  in  both  ears,  but  the 
patient  soon  becomes  unconscious,  and  there  is  at  the  same  time 
great  restlessness  and  delirium.  The  skin  is  hot  and  dry ;  the 
pupils  are  contracted  ;  there  may  be  strabismus ;  the  bowels  are 
constipated ;  vomiting  is  generally  an  urgent  symptom ;  and 
there  are  partial  convulsions,  which  may  be  followed  by  tran- 
sitory paralysis  of  the  extremities.  At  the  end  of  from  six  to 
ten  days  from  the  commencement  complete  coma  sets  in,  but 
at  the  end  of  four  or  five  days  longer  consciousness  gradually 

*  F^r^  et  Demars.     Revue  de  Medecine,  Oct.,  1881. 


NERVES  OF  SPECIAL  SENSE.  415 

returns,  and  the  cerebral  symptoms  abate.  When  the  child 
begins  to  "walk  it  is  noticed  that  he  has  a  tumbling  gait ;  older 
children  are  soon  discovered  to  be  deaf,  but  in  infants  the 
deafness  may  escape  notice  until  it  is  time  for  them  to  begin  to 
speak,  when  it  gradually  dawns  upon  the  parents  that  they  are 
deaf  and  dumb.  In  most  cases  the  hearing  is  destroyed  during 
the  febrile  period ;  in  other  cases  deafness  becomes  complete 
some  time  after  the  attack,  while  in  a  few  it  remains  incomplete. 
The  patient  gradually  recovers  from  his  tumbling  gait,  but,  as  a 
rule,  the  deafness  is  permanent. 

Morbid  Anatomy  and  Physiology. — It  is  maintained  by 
Voltolini^  and  Reichel^  that  the  symptoms  are  caused  by  a 
primary  purulent  labyrinthine  otitis,  but  Knapp^  believes  that 
the  affection  is  always  secondary  to  meningitis,  puerperal  fever, 
and  other  haemic  diseases,  and  he  compares  it  to  neuro-retinitis 
caused  by  extension  of  inflammation  from  the  arachnoid  cavity 
along  the  optic  nerves  to  the  eyeball.  That  the  latter  view  is 
correct  is  rendered  probable  by  the  fact  that  deafness  is  not  an 
unfrequent  consequence  of  epidemic  cerebro-spinal  meningitis, 
and  in  three  post-mortems  of  the  epidemic  disease  obtained  by 
Heller  and  Lucse  pus  was  found  in  the  labyrinth. 

Diagnosis  and  Prognosis. — The  affection  cannot  be  distin- 
guished from  meningitis,  and  it  is  only  in  cases  which  recover  from 
the  acute  affection  that  the  disease  can  be  recognised.  The 
disturbances  of  equilibrium  on  walking  disappear  after  a  time, 
but  the  deafness  is  incurable. 

Treatment. — The  acute  stage  of  the  disease  must  be  treated 
like  meningitis,  and  the  patient  must  be  trained  as  a  deaf  mute 
when  the  disease  has  begun  before  the  faculty  of  speech  is 
established. 

(IV.)-DISEASES   OF  THE   GUSTATORY  NERVES. 
§  224.  The   tongue   is  the  principal   organ  of  the  gustatory 
sense,  but  sensations  of  taste  are  also  perceived  by  part  of  the 
soft  palate,  by  the  arches  of  the  palate,  and  by  the  walls  of  the 

'Voltolini.  Monatsschr.  f.  Ohr.  Berl.,  1867,  p.  9;  1868,  p.  91;  1870,  pp.  91 
and  103.     Quoted  hy  Kna pp.     Loc.  cit.,  p.  283. 

^  lieichel.  "Otitis  acuta  intima  sive  Labyrinthica,  die  acute  Entziiadung  dea 
himtigen  Labyrinth."    BerL  med.  Wochenschr. ,  Bd.  XII.,  1870,  pp.  281  and  301. 

^  Knapp.     Loc.  cit.,  p.  246  et  seq. 


416  DISEASES  OF  THE 

pliar3mx.  But  the  root  of  the  tongue  and  the  pharyngeal  tissues 
on  the  one  hand,  and  the  anterior  half  of  the  tongue  on  the 
other,  receive  their  gustatory  fibres  from  different  nerves.  It 
may  be  accepted  as  proved  that  the  glosso-pharyngeal  nerve 
supplies  the  gustatory  fibres  distributed  over  the  posterior  part 
of  the  tongue,  the  palate,  and  the  walls  of  the  pharynx,  and  by 
the  mutual  contact  and  pressure  of  these  parts  the  sensations 
are  rendered  more  acute  and  distinct.  The  tip  and  anterior 
two-thirds  of  the  tongue  receive  their  gustatory  fibres  from  the 
lingual  nerve.  My  friend  Dr.  Noble^  was  the  first  to  advance 
the  opinion  that  taste  is  a  specific  sense,  and  not  a  mere 
modification  of  common  sensation,  as  had  been  previously 
taught.  From  one  point  of  view  all  the  special  senses  are 
modifications  of  common  sensations,  but  this  was  not  the  large 
and  extended  view  which  was  then  taken  of  the  sense  of  taste. 
Dr.  Noble  also  suggested  for  the  first  time  that  the  lingual  nerve 
derives  its  gustatory  fibres  from  the  chorda  tympani.  The 
case  which  suggested  this  view  to  him  was  that  of  a  woman, 
aged  fifty  years,  who  had  complete  angesthesia  of  the  left  half  of 
the  face  and  tongue,  but  without  being  accompanied  by  motor 
paralysis  or  by  any  diminution  of  taste.  In  reference  to  the  left 
half  of  the  tongue  Dr.  Noble  says  :  "  Its  common  sensibility  is  all 
but  destroyed.  To  impressions  of  taste,  of  pain,  of  the  rough 
or  the  smooth,  of  heat  or  of  cold,  she  is  all  but  insensible, 
while  to  impressions  of  the  bitter  or  the  sweet,  or  any  other 
modification  of  the  sense  of  taste,  she  is  as  acutely  alive  on  the 
affected  as  on  the  sound  half  of  the  tongue."  In  the  following 
year  Dr.  Noble^  reported  a  case,  the  symptoms  of  which  may  be 
regarded  as  the  converse  of  his  first  case ;  the  sense  of  taste  was 
lost  on  one  half  of  the  tongue,  while  common  sensation  was  pre- 
served in  it  and  the  corresponding  half  of  the  face.  It  has  been 
since  proved  by  experiments  on  animals  that  section  of  the 
chorda  tympani,  or  of  the  facial  nerve  at  any  point  where  it 
contains  the  fibres  of  the  chorda  tympani,  abolishes  or  retards 
the  perception  of  taste  in  the  anterior  part  of  the  tongue. 
Whether  all  the  gustatory  fibres  pass  from  the  lingual  nerve 
to  the  chorda  tympani,  or  part  of  them  remains  in  the  lingual 

1  Noble.    Medical  Gazette.    Vol.  XV.,  1835,  p.  120. 
'  Noble  (D.).    The  London  Medical  Gazette.    Vol.  XVII.,  1836,  p.  259. 


NERVES   OF   SPECIAL   SENSE. 


417 


nerve,  is  a  question  which  has  not  yet  been  finally  settled, 
but  the  chorda  tympani  undoubtedly  contains  a  very  consider- 
able part,  if  not  all,  of  the  gustatory  fibres  of  the  anterior  half 
of  the  tongue. 

Fig.  35. 

CA 


Fig.  35  (from  Hermann's  "  Physiology ").    Diagram  of  Glosso-Pkaryngeal  iferre, 
its  connections  and  branches. 

GP,  Glosso-phaiyngeal  nerve.     JG,  Its  jugular  ganglion.      PG,  Its  petrous 
ganglion. 

1,  Tympanic  branch,  or  nerve  of  Jacobson,  the  branches  of  which  are  as  follows: — 

2,  Filaments  to  plexus  on  carotid  artery ;  3,  To  Eustachian  tube ;  4,  To  fenestra 

rotunda;  5,  To  fenestra  ovalis. 

6,  Twig  of  union  with  small  superficial  petrosal  n. 

7,  Twig  of  union  with  great  superficial  petrosal  n. 
S,  Pharyngeal  branches  of  glosso-pharyngeal  n. 

9,  Muscular  branches  to  stylo-pharyngeus  and  constrictors  (?), 

10,  Tonsillitic  branches. 

11,  Terminal  lingual  branches. 

P,  Pneumogastric  nerve,  from  the  ganglion  of  the  root  of  which  branches  pass 

to  the  petrous  ganglion. 
S,  Superior  cervical  ganglion  with  an  ascending  branch  to  the  petrous  ganglion. 
MG,  Meckel's  ganglion.     OG,  Otic  ganglion.    F,  Facial  nerve.     CA,  Carotid 

artery. 


VOL.  I. 


BB 


418 


DISEASES   OF  THE 

Fig.  26. 


Fig.  36  (from  Landois'  "  Physiologie").  Semi-schematic  representation  of  the  Ocular 
Nerves,  along  with  the  Trigeminus  and  its  Ganglion,  the  Facial,  and  Glosso-pharyn- 
geal  Nerves. — 3,  Branch  of  the  oculo-motorius  to  the  inferior  oblique  muscle,  with 
a  thick  short  root  to  the  lenticular  ganglion  (c) ;  t,  ciliary  nerves ;  I,  long  root  of 


NERVES  OF  SPECIAL  SENSE.  419 

It  would  appear  that  the  greater  part  of  the  gustatory  fibres  pass 
from  the  lingual  nerve  to  the  chorda  tympani,  and  by  means  of  the  latter 
into  the  facial  nerve ;  but  there  are  good  groimds  for  beheving  that  on 
reaching  the  geniculate  ganglion  they  return  through  the  petrosal  nerves 
into  the  trigeminus  with  which  they  enter  the  cavity  of  the  skull  and  the 
brain.  The  following  is  the  chnical  evidence  which  may  be  advanced  in 
favour  of  this  opinion  : — 

(1)  Cases  of  complete  paralysis  of  the  facial  with  abolition  of  taste  in 
the  anterior  part  and  lateral  half  of  the  tongue  caused  by  disease  of  the 
facial  nerve  in  the  Fallopian  canal  above  the  point  at  which  the  chorda 
tympani  is  given  off  to  join  the  lingual  nerv^e.  Such  cases  are  often 
associated  with  caries  of  the  temporal  bone  or  suppuration  of  the  middle 
ear.  Several  cases  of  this  kind  have  come  imder  my  own  observation  and 
many  of  them  have  been  recorded  by  others. 

(2)  Cases  of  paralysis  of  the  facial  nerve,  caused  by  injury  of  it  at  the 
base  of  the  skull  and  above  the  geniculate  ganglion,  but  without  interference 
with  the  sense  of  taste. 

(3)  Cases  of  complete  anaesthesia  of  the  trigeminus  from  compression  of 
the  nerve  by  a  tumour  at  the  base  of  the  skull,  but  without  implication  of 
the  facial  nerve,  and  in  which  the  sense  of  taste  is  abolished  in  the  anterior 
two-thirds  of  the  lateral  half  of  the  tongue.  Cases  of  this  kind  have  been 
recorded  by  Romberg,^  Dixon,^  Lussana,*  and  Archer,*  although  some  of 
those  cases  do  not  possess  any  value  for  the  determination  of  this  question, 
inasmuch  as  coexisting  facial  paralysis  and  deafness  showed  that  the  seventh 
and  eighth  nerves  were  involved  in  the  lesion.     Two  unexceptional  cases 


the  ganglion  from  the  nasal  nerve  (nc) ;  s,  sympathetic  root  from  the  internal 
carotid  plexus  (G)  ;  d,  first  branch  of  the  trigeminus  (5)  with  the  nasal  (nc) 
branch  and  the  terminal  branches  of  the  lachrymal  {a),  supra-orbital  (b),  and 
frontal  (/)  nerves  ;  e,  second  branch  of  the  trigeminus  ;  R,  supra-orbital ;  n, 
spheno-paiatine  ganglion,  with  its  roots  {j )  from  the  facial,  and  iv)  from  the  sym- 
pathetic ;  N,  the  nasal  branch  ;  p,  p,  the  branches  of  the  ganglion  to  the  gums ; 
g,  third  branch  of  the  trigeminus  ;  k,  lingualis ;  i,  i,  chorda  tympani ;  'in,  otic 
ganglion,  with  its  roots  from  the  tympanic  and  carotid  plexuses,  and  from  the 
third  branch  of  the  fifth  ;  and  with  its  branches  to  the  auriculo  temporalis  (A) 
and  to  the  chorda  tympani  (i,  i) ;  L,  submaxillary  ganglion,  with  its  roots  from 
the  chorda  tympani,  lingualis,  and  the  sympathetic  plexus  of  the  external 
maxillary  artery  (q)  ;  7,  facial  nerves  ;  j,  superficial  petrosal  (major)  nerve  ; 
o,  geniculate  ganghon ;  /3,  branch  to  the  tympanic  plexus ;  y,  branch  to  stapedius ; 
S,  communicating  branch  to  auricular  branch  of  the  vagus ;  i,  i,  chorda  tym- 
pani ;  s,  stylo-mastoid  foramen  ;  9,  Glosso-pharyngeal  nerve,  A,  its  tympanic 
branch,  !r  and  e  communicating  branches  to  facial  nerve,  IJ,  termination  of 
the  gustatory  fibres  in  the  papillae  circumvallatse;  Sp,  sympathetic  with  (Gg  Sp) 
the  superior  cervical  ganglion ;  i,  ii,  iii,  iv,  the  four  upper  cervical  nerves  ; 
P,  parotid ;  M,  submaxillary  gland. 

*  Romberg.     The  Diseases  of  the  Nervous  System.     Syd.  Soc,  Vol.  II.,  p.  252. 

*  Dixon  (J.).     "  Two  cases  of  anaesthesia  and  loss  of  motony  function  of  the  fifth 
nerve."    Med.-Chir.  Transact.,  Vol.  XXVIII.,  1845,  p.  373. 

'  Lussana.     Gazz.  Med.  Ital.  Prov,  Venet.  XIII.     Abstr.  Centralbl.  f.  med. 
Wissensch.,  1871,  No.  15. 

*  Archer.     Cases  of  paralysis  of  the  trifacial  nerve.     British  Med.  Journal,  Vol. 
II.,  1878,  p.  514. 


420  DISEASES   OF   THE 

have  recently  been  communicated  by  Erb.^  In  one  case  there  was  anaesthesia 
in  the  whole  area  of  distribution  of  the  right  trigeminus,  and  loss  of  taste 
in  the  anterior  part  of  the  right  lateral  half  of  the  tongue,  while  the  presence 
of  blindness  and  paralytic  exophthalmos  of  the  right  eye  proved  that 
the  symptoms  were  caused  by  the  compression  of  a  tumour  in  the  anterior 
fossa  of  the  skull.  The  patient  was  practically  deaf  on  both  sides  from  an 
old  catarrh  of  the  middle  ear,  but  the  facial  nerves  were  not  diseased. 
In  the  other  case  there  was  partial  anaesthesia  of  the  left  half  of  the  face, 
along  with  redness  of  the  conjunctiva,  and  loss  of  common  sensation  and 
taste  in  the  anterior  part  of  the  tongue  on  the  same  side,  but  no  other 
symptom.  In  a  third  case  described  by  Erb  there  was  anaesthesia  of 
the  right  part  of  the  face  in  the  area  of  distribution  of  the  third 
branch  of  the  trigeminus,  while  the  areas  of  the  second  and  third 
branches  were  normal ;  the  symptoms  consisted  of  paralysis  and  atrophy 
of  the  masseter  of  that  side  and  loss  of  common  sensation  in  the 
anterior  lateral  half  of  the  tongue,  but  the  sense  of  taste  was  com- 
pletely preserved.  This  case  appears  to  show  that  the  gustatory  fibres  do 
not  pass  in  the  third  branch  of  the  trigeminus.  A  case  is  related,  however, 
by  Romberg,^  in  which  the  third  branch  of  the  left  fifth  nerve  was  alone 
diseased,  and  yet  there  was  loss  of  taste  in  the  left  lateral  half  of  the 
tongue.  At  the  autopsy  evidence  of  perineuritis  was  found  in  the  third 
branch  of  the  left  nerve,  at  the  point  where  it  passes  into  the  foramen 
ovale.  This  case,  therefore,  points  to  a  conclusion  directly  contrary  to  the 
case  reported  by  Erb.  A  curious  case  of  loss  of  taste  from  disease  of  the 
fifth  nerve  is  recorded  by  Gowers.*  The  patient,  a  woman  thirty-two  years 
of  age,  who  had  never  suffered  from  syphilis,  was  troubled  for  two  years 
with  diplopia,  paresis  of  the  internal  rectus  muscle  of  the  right  eye,  and 
attacks  of  dizziness  and  deafness.  Complete  anaesthesia  in  the  area  of 
distribution  of  all  the  branches  of  the  right  trigeminal  nerve  became 
suddenly  developed,  the  masseter  muscle  was  paralysed  and  atrophied, 
and  after  a  time  the  external  and  internal  recti  of  the  right  eye  were 
found  partially  paralysed.  The  chief  peculiarity  of  the  case  consisted  in 
the  fact  that  taste  was  abolished  in  the  right  lateral  half  of  the  tongue, 
posteriorly  as  well  as  anteriorly,  and  in  the  right  half  of  the  soft  palate 
and  right  tonsil.  The  author  thinks  that  the  symptoms  were  caused  by 
a  lesion  of  the  trigeminus  near  the  pons,  and  he  infers  that  all  the  gus- 
tatory fibres,  including  those  usually  supplied  by  the  glosso-pharyngeal 
nerve,  were  in  this  case  supplied  through  the  fifth  nerve.  The  fact, 
however,  that  the  right  internal  rectus  was  the  only  muscle  supplied  by 
the  third  nerve  which  was  paralysed  appears  to  me  to  render  it  probable 
that  the  lesion  was  situated  in  the  substance  of   the  pons,  the  partial 

'  Erb  (W.).  Ueber  den  Weg  der  geschmackvermittelnden  Chordafasern  zum 
Gehirn.     Neurologische  Centralbl.,  Vol.  I.,  1882,  pp.  74  and  104. 

^  Komberg.    A  manual  of  the  nervous  diseases  of  man.    Vol.  I.,  18.53,  p.  253. 

'^Gowers  (W.  E.).  "A  case  of  loss  of  taste  from  disease  of  the  fifth  nerve." 
Journal  of  Physiology,  Vol.  III.,  p.  229. 


NERVES   OF   SPECIAL   SENSE.  421 

l^aralysis  of  the  right  internal  rectus  being  caused  by  implication  of  the 
commissural  fibres  connecting  the  left  nucleus  of  the  sixth  with  the  right 
nucleus  of  the  third.  A  case  of  facial  paralysis  is  reported  by  Eulenburg^ 
caused  by  stretching  of  the  left  facial  nerve  for  the  ciue  of  spasmodic  tic, 
and  in  which  the  sense  of  taste  was  lost  for  fifteen  weeks  in  the  anterior 
half  of  the  left  side  of  the  tongue.  He  attributes  the  loss  of  taste  to  lesion 
of  a  filament  which  is  said  to  connect  the  peripheral  branches  of  the  glosso- 
pharyngeal and  facial  nerves.  Experiments  on  animals  undertaken  to 
determine  the  course  of  the  gustatory  fibres  are  liable  to  many  sources  of 
fallacy.  Schifi'^  found  that  section  of  the  trigeminus  at  the  base  of  the  skull, 
section  of  the  great  superficial  petrosal  nerve,  division  of  all  the  connections 
of  the  spheno-palatino  ganglion,  or  extirpation  of  the  ganglion  itself,  com- 
pletely abolishes  the  sense  of  taste  in  the  anterior  two-thii'ds  of  the  lateral 
half  of  the  tongue.  In  the  horse  and  calf  the  chorda  tympani  may,  according 
to  Owen,^  be  shown  by  dissection  to  be  continuous  with  the  great  superficial 
petrosal  nerve. 

So  far,  then,  as  our  present  knowledge  enables  us  to  judge,  the  following 
is  the  distribution  of  the  gustatory  nerves.  The  base  of  the  tongue,  the 
palate,  and  the  walls  of  the  pharynx  are  supplied  by  the  glosso-pharyngeal 
nerve  ;  the  anterior  two-thirds  of  the  tongue,  on-  the  other  hand,  is  sup- 
plied by  the  lingual,  but  the  gustatory  fibres  of  that  nerve,  either  alto- 
gether or  in  great  part,  enter  the  chorda  tympani,  then  run  in  the  facial  as 
far  as  the  geniculate  ganglion,  and  finally  return  by  many  and  stiU  imper- 
fectly known  paths  to  the  second  and  third  divisions  of  the  fifth  nerve,  in 
which  they  ascend  to  the  brain.  It  is  right,  however,  to  add  that  cases  of 
complete  paralysis  of  all  these  divisions  of  the  trigeminus  are  recorded,  and 
in  which  the  sense  of  taste  was  intact.* 

§  225.  Methods  of  Testing  the  Taste. 

It  ought  to  be  remembered  that  many  things  differ  considerably  in  taste 
according  as  they  are  perceived  by  the  anterior  or  posterior  portion  of  the 
tongue,  and  that  no  substance  can  be  tasted  unless  it  is  dissolved. 

When  the  acuteness  of  the  sense  of  taste  is  to  be  tested,  the  patient 
should  be  directed  to  put  his  tongue  out  with  the  mouth  widely  open  and 
the  eyes  closed,  whilst  the  sapid  substance  is  applied  on  the  particular  part 
to  be  tested  with  a  glass  rod  or  small  brush.  The  tongue  must  not  be 
withdrawn  into  the  mouth  until  time  is  given  for  the  taste  to  be  perceived, 
the  greatest  difiiculty  being  experienced  in  keeping  the  stimulus  circum- 

1  Eulenburg.  "  Ein  schwerer  Fall  non  Prosopospasmus  mit  ungewShnlichem 
Verlaufe."    Centralbl.  f.  Nervenh.,  1880,  p.  113. 

*  Schiff.     Centralbl.  f .  med.  Wissensch.    Bd.  XI.,  1873,  p.  943. 

^  See  Davidson.  "  On  the  sense  of  taste  and  its  relations  to  paralysis  and 
anaesthesia."  The  Liverpool  and  Manchester  Medical  and  Surgical  Eeports, 
Vol.  III.,  1875,  p.  198. 

*  Lussana.    Loc.  eit. 


422  DISEASES   OF  THE 

scribed  to  a  particular  part  of  the  tongue.  After  each  experiment  the 
tongue  must  be  prepared  for  a  fresh  trial  by  rinsing  the  mouth  out  with 
water. 

A  solution  of  quinine,  infusion  of  quassia,  or  solutions  of  various  other 
substances  are  employed  for  testing  hitter  tastes,  and  it  ought  to  be  remem- 
bered that  bitters  are  most  distinctly  perceived  at  the  root  of  the  tongue. 
Solution  of  sugar  or  honey  is  used  for  testing  the  taste  for  siveet  articles, 
which  are  most  distinctly  perceived  at  the  tip  of  the  tongue.  Vinegar 
and  diluted  acids  are  used  for  testing  acid  tastes,  which  are  chiefly  per- 
ceived by  the  edges  of  the  tongue.  Saliroe  tastes  are  tested  with  solutions 
of  common  salt,  or  bicarbonate  of  soda. 

The  galvanic  method  of  testing  the  sense  of  taste,  introduced  by 
Neumann,  is  very  valuable  for  the  investigation  of  pathological  cases.  Two 
fine  wires,  provided  with  small  knobbed  ends,  and  carefully  isolated  from 
one  another  by  means  of  seahng  wax,  are  to  be  attached  at  a  few  milh- 
metres  from  each  other  to  a  non-conducting  handle,  such  as  a  glass  rod  or 
an  elastic  catheter,  and  these  wires,  which  form  the  electrodes,  are  then 
connected  with  the  poles  of  galvanic  battery.  If  these  be  placed  upon  the 
dorsum  of  the  -tongue,  a  shght  bm-ning  sensation  is  felt  with  a  distinct 
sensation  of  taste,  which  is  stronger  at  the  anode  than  at  the  cathode, 
and  which  is  variously  desmbed  as  being  som-ish,  saline,  metallic,  &c. 
The  hmits  of  the  gustatory  and  non-gustatory  areas  may  be  accurately 
determined  by  this  means. 

The  neuroses  of  the  gustatory  nerve  may  be  subdivided  into 
two  groups,  the  first  of  which  includes  the  hypersesthesi^  and  the 
paragsthesise,  and  the  second  the  various  forms  of  ansesthesia, 

§  226.  Hypercesthesia  of  the  Gustatory  Nerves. — Hyperses- 
thesia  of  the  sense  of  taste  may  manifest  itself  as  an  increase 
in  the  delicacy  of  taste.  Hysterical  patients  sometimes  detect 
certain  ingredients  in  food  or  medicines  which  are  quite  imper- 
ceptible to  healthy  persons.  It  may  again  express  itself  as  an 
increase  in  the  enjoyment  or  loathing  of  food,  certain  substances 
causing  a  more  agreeable  or  disgusting  taste  than  they  do  in 
the  <3a«e  of  the  healthy  palate.  These  anomalies  chiefly  occur 
in  hysterical  patients.  Amongst  the  parcesthesice  of  the  sense 
of  taste  may  be  mentioned  the  subjective  sensations  which  are 
perceived  in  the  anterior  half  of  the  tongue  in  many  cases  of 
facial  paralysis  of  rheumatic  origin,  and  which  are  described  as 
being  sourish,  sweetish,  or  insipid  in  taste,  and  the  gustatory 
sensations  which  are  perceived  in  the  tongue  when  certain  drugs 
have  been  taken.     After  the  use  of  santanine,  for  instance,  even 


NERVES  OF   SPECIAL  SENSE.  423 

water  seems  to  have  a  bitter  taste,  and  an  intensely  bitter  taste  is 
often  experienced  during  attacks  of  jaundice.  The  subjective 
gustatory  sensations  of  insane  patients  are,  doubtless,  of  centric 
origin,  and  consist  partly  of  hallucinations,  and  partly  of  illu- 
sions of  taste. 

§  227.  Anaesthesia  of  the  Gustatory  Nerves  may  be,  as  regards 
its  intensity,  either  complete  or  incomplete,  and  the  diminution 
or  losa  of  taste  may  include  all  the  varieties  of  sapid  qualities, 
or  only  a  few  of  them.  The  anaesthesia  of  the  gustatory  sense 
may  also  be  circumscribed  or  diffused,  affecting  either  the  tip  of 
the  tongue,  its  root,  or  one  or  both  sides. 

Gustatory  anaesthesia  may  be  caused  by  all  conditions 
which  prevent  or  render  difficult  the  action  of  sapid  sub- 
stances upon  the  terminal  organs  of  the  gustatory  nerves. 
The  most  usual  of  these  conditions  are  a  coatiog  of  thick  fur, 
and  preternatural  dryness  of  the  mucous  membrane.  Agents 
which  lower  the  excitability  of  the  terminal  organs  also  blunt 
the  sense  of  taste,  such  as  cold,  or  even  excessive  heat,  for  it 
is  well  known  that  the  taste  of  hot  foods  is  not  recognised  with 
precision. 

The  most  usual  cause  of  gustatory  angesthesia  is  to  be  found  in 
disease  of  the  conducting  fibres.  The  lesion  may  be  situated  in 
the  course  of  the  glosso-pharyngeal,  trigeminal,  lingual,  chorda 
tympani,  and  facial  nerves.  When  the  glosso-pharyngeal  is 
affected,  taste  is  weakened  or  abolished  on  the  corresponding 
side  of  the  root  of  the  tongue,  palate,  and  pharynx.  No  uncom- 
plicated case  of  this  nature  is,  however,  on  record.  Jacubowitch^ 
has  described  the  case  of  a  leprous  patient  who  was  unable  to 
perceive  either  bitter  or  acid  flavours,  but  recognised  sweets 
and  salines  perfectly.  The  morbid  changes  which  have  been 
found  in  leprosy  lead  us  to  suppose  that  in  this  case  there  was 
perineuritis  of  the  glosso-pharyngeal  nerves.  If  the  lesion  is 
situated  in  the  trigeminal  and  lingual  nerves,  or  in  the  chorda 
tympani  and  certain  sections  of  the  facial  nerves,  the  gustatory 
anaesthesia  affects  the  anterior  half  of  the  tongue,  along  with  its 
border  and  apex.     When  loss  of  taste  in  the  areas  of  distribu- 

1  Jacubowitch  (J.).    "Zur  Geschmacksempfinding."    Hoffmann  und  Schwalbe's 
Jahresberichte,  Bd.  I.,  1872,  p.  572. 


424j  DISEASES  OF  THE  NERVES  OF  SPECIAL  SENSE, 

tion  of  the  liogual  and  giosso-pharyngeal  nerves  of  one  side  is 
associated  with  hemi-ansesthesia  of  the  same  side  of  the  body,  it 
may  be  inferred  that  the  lesion  is  central,  such  a  combination  of 
symptoms  being  generally  met  with  in  hysteria.  Little  is  known 
with  regard  to  disease  of  the  perceptive  centres  of  taste. 

The  diagnosis  must  be  made  by  a  careful  objective  investiga- 
tion, according  to  the  methods  previously  described. 

The  'prognosis  depends  upon  the  nature  of  the  primary  disease. 

The  treatment  must  be  mainly  directed  to  remove  the  cause 
of  the  disease ;  the  best  direct  treatment  is  the  application  of 
faradisation  or  galvanisation,  either  directly  to  the  tongue  itself, 
or  through  the  lingual  nerve,  or  the  current  may  be  passed 
through  the  head,  the  poles  being  applied  over  the  temples  or 
the  mastoid  processes. 


425 


CHAPTER    IV. 


DISEASES   OF   THE   MOTOR   CRANIAL   NERVES— (OCULAR, 
FACIAL,   AND   HYPOGLOSSAL   NERVES). 

(I. )— DISEASES   OF  THE   OCULAR   MOTOR   NERVES. 

The  ocular  motor  nerves  are  the  oculo-motorius,  trochlearis,  and 
abducens,  and  since  they  are  so  closely  related  to  each  other, 
both  in  their  functions  and  anatomical  distribution,  it  will  be 
convenient  to  form  one  group  of  the  diseases  to  which  they  are 
liable.  The  subjoined  diagram  will  suffice  to  remind  the  reader 
of  the  course  and  distribution  of  these  nerves. 


Fig.   37   (from   Hermann's   "Physiology").     Diagram  of  the  First  or  Ophthalmic 
Division  of  the  Fifth,  showing  also  the  Third,  Fourth,  and  Sixth  Cranial  Nerves. 

V,  Sensory  root  of  fifth  nerve. 

GG-,  Gasserian  ganglion  on  larger  root  of  the  fifth  nerve. 
a,  Ophthalmic  division  of  the  fifth  nerve. 

1,  Frontal  nerve.     2,  Lachrymal  nerve.     3,  Nasal  nerve. 
LGr,  Lachrymal  gland. 

3',  Infra-trochlear  branch  of  nasal  nerve. 
3",  Long  ciliary  branches  of  nasal  nerve. 
3'",  Branch  of  nasal  nerve  to  ophthalmic  ganglion, 
OG,  Ophthalmic  ganglion. 

_  6,  Second  division  of  fifth  cut  across,     c,  Third  division  of  fifth  cut  across. 

III,  Third  nerve  (motorius  oculi). 

4,  Upper  division  of  third  nerve.       5,  Lower  division  of  third  nerve,  near 
point  where  it  gives  the  short  root  to  the  ophthalmic  ganglion. 

IV,  Fourth  nerve  (n.  trochlearis). 

7,  Its  fibres  passing  to  the  superior  oblique. 

VI,  Sixth  nerve  (n.  abducens). 

6,  Its  fibres  passing  to  external  rectus. 
CA,  Carotid  artery.  E,  Vertical  section  through  anterior  part  of  eyeball ; 

conjunctiva  indicated  by  dotted  line, 


426  DISEASES   OF   THE  MOTOE   CEANIAL   NERVES. 

§  228.  Muscles  of  the  Eye. 

The  muscles  of  the  eye  and  its  accessories  maybe  divided  into 
(A)  external  and  (B)  internal  muscles,  and  the  former  group 
may  be  subdivided  into  (I.)  muscles  of  the  eyelids  and  (II.) 
tnuscles  of  the  eyeball. 

(A)  External  Muscles  of  the  Eye. 

(I.)   I\IUSCLES   OP   THE   EyELIDS. 

The  movements  of  the  eyelids  are  regiilated  by  two  muscles,  the  levator 
palpehrce  superioris,  and  the  orbicularis  palpebrariini.  The  levator  muscle 
is  the  only  one  which  is  supplied  by  the  ocular  motor  nerves,  but  its  action 
cannot  be  fully  -understood  without  taking  that  of  the  orbicular  into  con- 
sideration. During  waking  hours  the  Hds  are  kept  open  partly  by  the  tonic 
action  of  the  levator  i^reponderating  over  that  of  the  orbicular,  and  partly 
by  the  pressiu-e  of  the  globes  against  the  hds.  That  the  latter  factor  takes 
part  in  maintaining  the  lid  open  is  shown  by  the  facts  that  when  the 
fibres  of  Miiller  are  paralysed,  the  eyeball  falls  further  back  into  the  orbit, 
and  the  palpebral  fissure  is  diminished  in  size  ;  conversely,  when  these 
fibres  are  contracted,  the  eyeball  becomes  prominent,  and  the  size  of  the 
palpebral  fissure  is  increased.  When  the  fissure  is  open  the  margin  of  the 
hds  are  semi-lunar;  the  concavity  of  the  lower  being  directed  upwards, 
and  of  the  upper  downwards.  When  the  orbicular  contracts  the  fibres 
23assing  from  the  inner  and  outer  canthi  become  shortened,  and  the 
margin  of  the  Hds  lose  their  semilunar  form  and  become  straight ;  in 
addition,  there  is  a  shght  elevation  of  the  lower  and  a  greater  depression  of 
the  upper  Hd,  and  thus  the  margins  meet.  The  opening  and  closing  of  the 
Hds  must  be  regarded  as  a  volimtary  action,  inasmuch  as  the  movements 
may  be  effected  without  caUing  any  other  muscles  into  action.  In  forcible 
closing  of  the  eyes  the  eyebrows  become  knit,  showing  that  the  corrugator 
superciHi  has  also  contracted,  but  the  orbicular  muscle  takes  the  lead  in  this 
action,  and  its  contraction  must  still  be  regarded  as  volimtary.  But  aH  the 
other  movements  of  which  the  Hds  are  capable  appear  to  be  either  associated 
or  mechanical  movements.  The  Hds  move  up  and  down  according  as  the  eye- 
lids are  turned  upwards  or  downwards.  The  surface  of  the  eyebaU  pre- 
sents, as  has  been  pointed  out  by  Dr.  Gowers,^  two  curves,  one  of  the  cornea 
and  the  other  of  the  sclerotic,  a  depression  being  observed  at  the  jimction 
of  the  two,  which  he  names  the  sclero-comeal  sulcus.  Now,  when  the  eyes 
are  turned  upwards,  the  convexity  of  the  sclerotic  moves  forwards  and 
upwards,  so  that  it  forms  a  prominence  under  the  lower  Hd,  which  may  be 
felt  by  the  finger  ;  the  Hd  is  then  stretched,  its  margin  loses  its  semilunar 
form  and  becomes  straight,  and  its  middle  portion  is  at  the  same  time 

^Growers  (W.  R.).  "The  movements  of  the  eyelids."  Medico-Chirurgical 
Transactions,  Vol.  LXII.,  1879,  p.  429. 


DISEASES   OF   THE  MOTOR   CRANIAL   NERVES.  427 

elevated,  but  it  does  not  move  further  upwards  and  consequently  a 
considerable  ix)rtion  of  the  sclerotic  immediately  under  the  cornea 
becomes  exposed.  When  the  eyeball  is  turned  down  the  margin  of  the 
lower  lid  first  assumes  its  normal  semilunar  form,  and,  on  the  continu- 
ance of  the  downward  movement,  it  is  carried  somewhat  further  down  by 
the  pressure  of  the  corneal  convexity  against  it.  The  upward  and  down- 
ward movements  of  the  lower  lid  in  conjunction  with  similar  movements  of 
the  eyeball  appear,  therefore,  to  be  entirely  owing  to  the  mechanical  pressure 
of  the  eyeball  against  it.  But  the  upper  hd,  in  most  persons  at  least,  covers 
a  considerable  portion  of  the  cornea  when  the  patient  looks  at  an  object  in 
front  of  him  on  a  level  with  his  eyes,  and  consequently  the  pressure  of  the 
convexity  of  the  cornea  against  the  margin  of  the  lid  cannot  be  supposed 
to  have  much  influence  in  carrying  the  lid  upwards  during  upward  rotation 
of  the  eyeball.  This  movement  appears  to  be  wholly  effected  by  an  asso- 
ciated contraction  of  the  levator  palpebroe  superioris.  The  downward 
movement  of  the  upper  lid  simidtaneously  with  downward  rotation  of  the 
eyeball  is  more  difficult  to  understand.  It  does  not  seem  to  depend,  at 
least  to  any  appreciable  extent,  upon  mechanical  action  like  the  movement 
of  the  lower  hd,  nor  does  it  appear  to  depend  upon  contraction  of  the  orbi- 
cular muscle,  inasmuch  as  the  movement  may  be  arrested  by  a  finger 
placed  over  the  lid  during  the  downward  rotation  of  the  eye  without  the 
slightest  muscular  resistance  being  felt.  The  downward  movement  of  the 
lid  ap]pears  to  be  due,  as  Dr.  Gowers  suggests,  to  a  kind  of  ptosis  caused 
by  a  gradual  relaxation  of  the  levator,  corresponding  to  a  similar  gi'adual 
relaxation  of  the  superior  rectus,  and  simultaneously  with  a  proportional 
contraction  of  the  inferior  rectus.  The  prominence  of  the  sclerotic,  as  it 
moves  forwards  and  downwards,  doubtless  assists  in  depressing  the  Hd, 
but  this  cause  alone  could  have  little  influence  upon  it  were  the  levator  to 
remain  contracted.  The  relaxation  of  the  levator  palpebrae  and  superior 
rectus  coincidently  with  the  contraction  of  the  inferior  rectus  is  most 
probably  caused  by  an  inhibitory  influence  being  sent  from  the  cortex  to 
the  motor  ganglion  cells  which  regulate  the  movements  of  the  former 
muscles  at  the  same  time  that  an  excitant  influence  is  sent  to  the  ganglion 
cells  which  regulate  the  action  of  the  latter  one.  It  is  most  likely  that  this 
principle  is  applicable  to  a  great  many  other  movements  beside  those  of 
the  eye  and  eyelids.  When,  for  instance,  I  flex  my  hand  at  the  wrist  I  am 
not  conscious  that  any  resistance  is  offered  by  the  antagonist  muscles  to 
the  movement  imtil  extreme  flexion  is  attained,  and  then  the  extensors  feel 
stretched.  It  is  then  probable  that  an  inhibitory  influence  is  sent  to  the 
nerve  nuclei  of  the  extensors  simultaneously  with  an  excitant  influence  to 
the  nuclei  of  the  flexors  of  the  hand.  But  when  I  grasp  an  object  firmly  in 
my  hand  not  only  are  the  flexors  active,  but  the  extensors  also  may  be  felt 
to  be  strongly  contracted.  And  the  muscles  which  effect  opposite  move- 
ments of  the  eyeball  may  under  certain  circumstances  likewise  be  made  to 
contract  simultaneously.  When  I  stare,  for  instance,  I  feel  as  if  all  the 
muscles  of  the  eyeballs  were  simultaneously  active ;  the  levators  are  at  the 


428  DISEASES   OF   THE   MOTOR   CRANIAL   NERVES. 

same  time  strongly  contracted,  and  retract  the  upper  lids  so  that  a  complete 
rim  of  the  sclerotic  is  seen  around  each  cornea ;  the  pupils  become  smaller ; 
and  even  the  ciliary  muscle  is  simultaneously  contracted,  inasmuch  as  a 
person  while  staring  must  bring  small  objects  nearer  to  his  eye  in  order  to 
obtain  clear  vision. 

§  229.  Disorders  of  the  Movements  of  the  Eyelids. 

(1)  The  levator  palpehrm  superioris  is  but  seldom  affected  by- 
tonic  spasm  as  an  isolated  affection,  and  hardly  ever  by  clonic 
spasm.  Tonic  spasm  of  the  levator  of  the  upper  lid  causes  the 
lid  to  be  drawn  upwards,  and  there  is  consequent  inability  to  close 
the  eye,  either  by  voluntary  effort  or  during  sleep.  The  causes 
of  tonic  spasm  of  this  muscle  may  be  either  direct  peripheral 
irritation  as  in  traumatic  and  rheumatic  cases,  indirect  reflex 
irritation  of  the  terminal  branches  of  the  fifth,  or  central  irritation. 
The  orbicular  muscle  is  liable  to  tonic  and  clonic  spasms,  but 
these  will  be  described  along  with  other  diseases  of  the  facial 
nerve. 

(2)  Paralysis  of  the  levator  palpehrce  superioris,  or  ptosis, 
may  occur  as  a  separate  affection,  the  result  of  injury,  or  spon- 
taneously, but  it  is  usually  associated  with  paralysis  of  the 
superior  rectus,  which  is  also  supplied  by  the  superior  branch 
of  the  oculo-motor  nerve.  The  upper  lid  hangs  motionless,  the 
palpebral  fissure  is  greatly  narrowed,  and  when  the  eye  is 
directed  upwards  the  lid  is  not  raised,  and  the  horizontal 
wrinkles  of  the  upper  lid  are  effaced. 

(3)  Disorder  of  the  associated  and  mechanical  movements 
of  the  muscles  of  the  eyelids. — A  curious  disorder  of  the  move- 
ments of  the  eyelids,  first  described  by  Dr.  Gowers,^  may  be 
observed  in  incomplete  paralysis  of  the  oculo-motorius.  In  a 
case  of  syphilitic  disease  of  the  third  nerve  of  the  right  side, 
at  present  under  my  care,  the  patient  manifests  a  slight  degree 
of  the  usual  symptoms  of  the  affection.  When  the  patient 
looks  straight  forwards  {Fig.  38)  a  slight  external  squint  of 
the  right  eye  is  perceptible,  and  the  palpebral  aperture  on 
that  side  is  a  little  smaller  than  the  opposite  one  from  a 
slight  degree  of  ptosis.  When  the  patient  looks  up  {Fig.  39) 
the  left  or  healthy  eye  is  rotated  upwards,  and  there  is  a  simul- 

'  Gowers.    Loc.  cit. 


DISEASES   OF   THE   MOTOR   CRANIAL   NERVES. 


429 


taneous  upward  movement  of  both  eyelids  on  that  side,  but,  as 
usual,  the  eye  has  gained  upon  the  lower  lid,  so  that  a  con- 


FiG.  38. 


siderable  portion  of  the  sclerotic  between  the  lower  margin  of 
the  cornea  and  the  edge  of  the  lid  is  uncovered.  The  right  eye, 
however,  has  scarcely  moved,  and  the  lids  have  also  remained 


Fig.  39. 


almost  stationary.  It  may  be  supposed  that  the  immobility  of 
the  lid  is  caused  by  paralysis  of  the  levator,  but  the  ptosis  in 
this  case  is  so  slight  as  to  be  scarcely  perceptible,  and  conse- 


430  DISEASES   OF  THE  MOTOE   CRANIAL  NERVES. 

quently  the  degree  of  paralysis  present  is  hardly  sufficient  to 
account  for  the  all  but  complete  immobility  of  the  lid.  When 
the  patient  is  asked  to  look  down  the  disorder  in  the  movements 
of  the  eyelids  becomes  still  more  remarkable  and  apparent.  The 
left  upper  eyelid  has  moved  downwards  in  association  with  the 
downward  rotation  of  the  eyeball  in  a  perfectly  normal  manner 
{Fig.  40),  but  both  the  right  eyeball  and  upper  eyelid  have 

Fig.  40. 


remained  comparatively  stationary,  so  that  the  patient  presents 
the  singular  apearance  of  looking  with  the  left  eye  at  an 
object  lying  at  her  feet,  while  the  right  eye  seems  to  be 
looking  at  an  object  almost  on  a  level  with  the  eye.  That 
the  immobility  of  the  right  upper  eyelid  during  this  move- 
ment is  not  caused  by  paralysis  of  the  orbicularis  is  readily 
shown  by  asking  the  patient  to  close  her  eyes,  which  she  does 
with  the  greatest  freedom  and  ease.  She  can  even  wink  the 
right  eye  and  close  it  by  a  voluntary  effort  while  leaving  the  left 
open.  The  perfectly  normal  manner  in  which  the  right  eye  is 
closed  shows  also  that  the  immobility  of  the  lid  during  an 
attempted  downward  rotation  of  the  eyeball  is  not  caused  by 
spasm  of  the  levator,  the  presence  of  which  would  give  rise  to 
some  degree  of  difference  in  the  modes  of  closure  of  the  right 
and  of  the  left  eyelids.     The  immobility  of  the  right  eyelids, 


DISEASES   OF   THE  MOTOR  CRANIAL  NERVES.  431 

therefore,  must  be  chiefly  due  to  an  arrest  of  the  associated 
contraction  and  relaxation  of  the  levator  palpebrse,  which  occur 
during  upward  and  downward  rotation  of  the  eyeball  respectively. 

(II.)  External  Muscles  of  the  Eyeball. 

The  eyeball  is  moved  by  six  muscles — the  recti  inferior,  superior, 
internus  and  externus,  and  the  obliqui  inferior  and  superior.  These  muscles 
may  be  considered  as  three  pairs,  each  pair  rotating  the  eye  round  a  par- 
ticular axis.  Each  eye  is  capable  of  rotating  round  an  immobile  centre  of 
rotation,  its  position  being  a  little  behind  the  centre  of  the  globe,  and  where 
the  horizontal  and  vertical  axes  intersect.  The  primary/  position  of  the  eye 
is  that  which  may  be  attained  by  looking  at  the  distant  horizon  with  the 
head  vertical  and  the  body  upright.  The  visual  axes  are  then  parallel  to 
one  another,  and  to  the  median  plane  of  the  head.  All  other  positions  of 
the  eye  are  called  secondly  positions.  A  vertical  plane  drawn  through  the 
centre  of  rotation  at  right  angles  to  the  primary  visual  axis  is  of  importance, 
inasmuch  as  every  change  from  the  primary  to  a  secondary  position  is 
brought  about  by  a  rotation  of  the  eye  round  an  axis  lying  in  this  plane 
(Listing).  The  chief  axes  in  this  plane  are  the  transverse,  rotation  round 
which  causes  the  eye  to  move  up  and  down,  and  the  vertical,  rotation  round 
which  causes  the  eye  to  move  from  side  to  side.  Rotation  round  other  axes 
in  this  plane  causes  oblique  movements. 

The  various  movements  of  the  eyeball  may  be  arranged  as  follows  :^ 

•«.  ■§  /'Elevation Eectus  superior  and  obliquus  inferior. 

.g>  I  J  Depression    Rectus  iuf erior  and  obliquus  auperioz'. 

Is  ^  )  Adduction  to  nasal  side    Rectus  internus. 

^  \  Abduction  to  malar  side Rectus  externus. 

■2  /Elevation  with  adduction    Rectus  superior  and  internus  with  obliquus  inferior. 

§,  s  )  Depression  with  adduction  . . .  .Rectus  inferior  and  internus  with  obliquus  superior. 
;S  s  ]  Elevation  with  abduction    ....  Rectus  superior  and  externus  with  obliquus  inferior. 

1^  \ Depression  with  abduction  . . .  .Rectus  inferior  and  externus  with  obliquus  superior. 

§  280.  Disorders  of  the  movements  of  the  External  Muscles  of 

the  Eyeball. 
1. — Spasms  of  the  External  Muscles  of  the  Eyeball. 

The  muscles  of  the  eyeballs  are  subject  to  both  tonic  and 
clonic  spasms. 

(1)  Tonic  spasm,  of  the  internal  rectus  is  met  with  more 
frequently  than  spasm  of  any  other  muscle  of  the  eyeball, 
and  it  is  usually  associated  with  blepharospasm  (Galezowski), 
Many  cases  of  temporary  strabismus  which  appear  as  premonitory 

'  Foster  (Dr.  M.).  A  Text-book  of  physiology.  Lond.,  1877.  p.  386.  See  also 
von  Graefe  (A.).  Des  paralysies  des  muscles  moteurs  de  I'oeil  Traduit  de  I'alle- 
mand,  par  A.  Sichel.    Paris,  1870.    p.  106. 


432 


DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 


symptoms  of  cerebral  disease,  or  in  consequence  of  the  reflex 
irritation  of  teething  in  children,  after  fright,  or  other  emotional 
disturbances,  are  due  to  spasm  of  the  internal  rectus.  Spasm  of 
the  internal  rectus  gives  rise  to  homonymous  diplopia,  similar  to 
that  which  occurs  in  paralysis  of  the  sixth  nerve.  Paralysis  of 
the  sixth  nerve,  however,  causes  a  permanent  squint,  and  the 
relative  positions  of  the  true  and  false  images  are  more  or  less 
fixed,  but  in  spasm  of  the  internal  rectus  there  is  a  constant 
oscillation  between  the  two  images  which  alternately  approach 
and  recede  from  each  other.  All  cases  of  spasmodic  strabismus 
are  accompanied  by  paroxysms  of  neuralgia,  which  extend  over 
one  half  of  the  head.  It  is  often,  also,  associated  with  photo- 
phobia and  lachrymation.  Tonic  spasm  of  the  internal  rectus 
may  be  caused  by  long-standing  paralysis  of  its  antagonist,  the 
external  rectus. 


Fig.  41. 


Fig.  41  (from  Landois'  "  Physiologie").  Diagram  of  the  Attachments  of  the  Muscles 
of  the  Eye,  and  of  their  Axes  of  Rotation,  the  latter  being  represented  hy  dotted 
lines. — S,  S,,  The  visual  axis  joining  the  centre  of  the  cornea  and  the  fovea 
centralis  retinee.  Q,  Qi,  The  transverse  axis.  The  vertical  axis  cannot_  be 
represented,  being  perpendicular  to  the  plane  of  the  paper.  Where  the  vertical 
axis  passes  through  the  horizontal  axis  is  the  centre  of  rotation. 


DISEASES   OF   THE  MOTOR  CRANIAL  NERVES.  433 

(2)  Tonic  spasm  of  the  external  rectus  is  rare  as  an  isolated 
ajffectioD,  but  Galezowski  has  observed  it  alternate  with  spasm 
of  the  internal  rectus  in  a  case  of  locomotor  ataxy.  Spasm  of 
this  muscle  causes  divergent  squint,  and  gives  rise  to  diplopia 
with  crossed  images ;  but  contrary  to  what  occurs  in  paralysis, 
the  two  images  never  remain  fixed,  but  alternately  approach 
and  recede  from  each  other. 

The  causes  of  spasmodic  strabismus  are  generally  the  same  as 
those  which  give  rise  to  spasm  of  other  muscles.  It  is  necessary 
to  examine  with  care  for  any  source  of  irritation  in  the  region  of 
distribution  of  the  fifth  nerve,  such  as  carious  teeth.  Exposure 
to  cold,  and  especially  exposure  of  one  side  of  the  face  to  a  cold 
current  of  air,  predisposes  to  this  affection. 

Treatment. — The  treatment  must  be  directed  against  the 
cause  of  the  spasm  whatever  it  may  be,  whether  it  be  reflex,  or 
direct  irritation,  or  of  central  origin. 

(3)  Nystagmics  consists  of  a  clonic  spasm  of  the  muscles  of 
the  eyeballs,  giving  rise  to  continual  oscillatory  or  rotatory  move- 
ments, which  are  entirely  beyond  the  control  of  the  patient.  The 
ocular  tremors  sometimes  consist  of  lateral  oscillatory  move- 
ments, when  the  external  and  internal  recti  are  mainly  impli- 
cated ;  while,  at  other  times,  the  movements  are  rotatory,  and 
then  the  oblique  muscles  are  mainly  affected.  When  the  patient 
looks  at  a  remote  object,  the  trembling  becomes  very  pronounced, 
and  the  eyes  become  more  and  more  fixed  in  proportion  as  they 
are  directed  to  near  or  small  objects.  Nystagmus  is  always 
bilateral  even  when  one  eye  is  completely  blind. 

Etiology, — The  causes  of  nystagmus  are  of  two  kinds,  local 
and  central.  Amongst  the  local  causes  may  be  mentioned  con- 
genital defects  of  the  optic  nerves  and  retinse,  pigmentary  retinitis, 
congenital  cataract,  and  corneal  opacities. 

Nystagmus  of  central  origin  appears  to  result,  as  a  rule,  from 
disease  of  one  or  other  of  the  cerebellar  peduncles.  Friedreich 
has  observed  nystagmus  in  certain  cases  of  locomotor  ataxy,  and 
in  these  it  is  probable  that  the  lesion  of  the  posterior  columns 
had  extended  to  the  restiform  bodies.  This  affection  is  often 
met  with  in  insular  sclerosis,  and  in  these  cases  the  diseased 
patches  appear  to  be  scattered  about  the  cerebellum  and  its 
peduncles.  Nystagmus  may  also  arise  in  connection  with  basal 
VOL.  I.  CC 


434  DISEASES   OF  THE  MOTOR  CRANIAL  NERVES, 

meningitis,  hydrocephalus,  and  other  intracranial  processes.     It 
is  often  present  in  albinos,  aad  colliers  are  frequently  affected. 

Treatment — In  many  cases  nystagmus  does  not  produce  any 
disturbance  of  vision,  and  consequently  no  interference  is  indi- 
cated. In  other  cases  the  disease  is  secondary,  and  the  treat- 
ment must  be  directed  against  the  primary  affection.  In  cases 
of  hypermetropia,  myopia,  or  astigmatism,  the  use  of  appro- 
priate glasses  is  indicated.  If  the  trembling  be  due  to  spasm,  or 
shortening  of  one  or  more  of  the  ocular  muscles,  tenotomy  must 
be  had  recourse  to.  In  cases  of  more  or  less  temporary  nystag- 
mus all  sources  of  irritatioD,  such  as  carious  teeth,  or  diseases  of 
remote  organs,  as  the  intestines  and  uterus,  must  be  attended  to. 

2. — Paralysis  of  the  External  Muscles  of  the  Eyeball. 

General  Remarks. — Paralyses  of  the  ocular  muscles  are  not 
only  of  frequent  occurrence,  but  they  form  most  important 
symptoms  in  different  cerebral  and  spinal  diseases ;  it  is  there- 
fore desirable  that  their  presence  should  be  detected  and  their 
varieties  accurately  determined. 

General  Etiology. — Paralysis  of  one  or  more  of  the  ocular 
muscles  occurs  sometimes  from  exposure  to  cold,  and  is  then 
supposed  to  be  of  rheumatic  origin.  The  abducens  and  oculo- 
motorius  are  the  nerves  most  usually  affected,  and  the  paralysis 
is  often  limited  to  a  few  of  their  branches.  The  trochlear  nerve 
is  seldom  affected. 

The  next  most  common  causes  of  paralyses  of  these  nerves  are 
blows  on  the  eyes,  penetrating  wounds  of  the  orbit,  and  fractures 
of  the  skull.  Another  important  cause  is  mechanical  compression 
of  the  ocular  nerves,  either  in  the  orbit  or  in  their  course  along 
the  base  of  the  skull.  Compression  is  produced  by  new  forma- 
tions, aneurisms,  extravasations  of  blood,  syphilitic  affections, 
and  basal  meningitis.  Neuritis  arising  either  idiopathically,  or 
in  consequence  of  injury,  also  gives  rise  to  paralysis.  Paralysis 
of  some  of  the  ocular  muscles  is  associated  with  bulbar  paralysis 
and  is  frequently  met  with  in  locomotor  ataxy. 

Syphilis  is  a  frequent  cause  of  paralysis  of  the  ocular  muscles, 
and  one  of  the  most  common  nervous  symptoms  which  occur  in 
the  later  stages  of  this  disease  is  paralysis  of  some  of  these 
muscles.     Yarious  anatomical  changes  may  be  the  cause  of  the 


DISEASES   OF  THE  MOTOR   CRANIAL   NERVES.  435 

paralysis,  as  periostitis  and  exostoses  of  the  orbit  or  base  of  the 
skull,  or  gummata  at  various  points  in  the  course  of  the  nerves 
or  in  the  brain. 

Dii^ktheHa  is  also  a  frequent  cause  of  paralysis  of  certain 
branches  of  the  oculo-motorius.  Ocular  paralysis  may  likewise 
occur  after  other  acute  diseases,  or  exposure  of  the  eye  to  strong 
impressions  of  light,  excessive  smoking,  alcoholic  abuse,  and 
similar  irregularities. 

§  231.  General  Symptoms. 

Diplopia. — If,  when  the  visual  axis  of  one  eye  is  directed  to 
an  object  desired  to  be  seen,  the  direction  of  the  other  deviates 
to  some  extent  from  that  object,  the  image  in  the  distorted  eye 
falls  on  an  eccentric  portion  of  the  retina,  and  two  objects  in- 
stead of  one  are  seen.  The  image  seen  by  the  healthy  eye  forms 
on  the  macula,  and  it  is  consequently  distinct,  while  the  image 
seen  by  the  distorted  eye  forms  upon  a  more  or  less  peripheric 
region  of  the  retina,  and  it  is  consequently  faint  and  more 
or  less  confused ;  the  former  is  therefore  called  the  true,  and  the 
latter  the  false,  image.  This  symptom  is  common  to  all  forms  of 
paralyses  of  the  ocular  muscles,  and  is  called  binocular  diplopia. 
The  more  completely  the  muscle  is  paralysed  the  greater  is  the 
angle  of  deviation,  and  the  more  marked  does  the  diplopia 
become. 

^Neutralisation  of  the  False  Image. — When  the  paralysis  is  of 
old  date  the  patient  learns  to  perceive  objects  only  with  the 
healthy  eye,  and  the  diplopia  disappears;  whilst  the  distorted 
eye,  from  long-continued  disuse,  suffers  consecutive  amblyopia. 
The  diplopia,  however,  may  be  made  to  reappear  by  placing 
before  the  healthy  eye  a  coloured  glass,  which  differentiates  the 
true  image  and  permits  that  of  the  distorted  eye  to  be  perceived. 

Eolations  of  the  Images  to  one  another. — When  one  of 
the  images  is  coloured,  that  of  each  eye  is  readily  recognised. 
Assuming  the  left  eye  to  be  affected,  the  false  image  is  dis- 
placed horizontally  to  the  patient's  ri^ht  in  outward  squint 
(Fig.  42,  1),  horizontally  to  the  patient's  left  in  inward  squint 
(Fig.  42,  2) ;  while  the  false  is  above  the  true  image  (Fig.  42, 
3  and  4)  in  downward,  and  below  it  in  upw.ard  squint  (Fig.  42, 
5  and  6).     It  will  thus  be  seen  that  the  false  image  assumes  an 


436  DISEASES   OF  THE  MOTOR  CRANIAL   NERVES. 

opposite  position  to  the  distortion  of  the  eye.  In  outward  or 
inward  squint  the  images  are  vertical  and  parallel  with  one 
another,  but  in  all  other  forms  of  distortion  the  globe  becomes 
rotated  on  its  oblique  axis  by  the  unantagonised  action  of  one 
or  other  of  the  oblique  muscles,  and  the  false  assumes  an  oblique 
position  with  reference  to  the  true  image,  or,  in  other  words,  the 
false  image  is  tilted  {Fig.  42,  3,  4,  5,  and  6).  The  false  image  is 
tilted  in  the  opposite  direction  to  the  rotation  of  the  eye.  When, 
for  instance,  the  superior  oblique  of  the  left  eye  is  paralysed,  the 
upper  margin  of  the  globe  is  rotated  outwards  to  the  left  by  the 
unantagonised  action  of  the  inferior  oblique  muscle,  and  the 
upper  end  of  the  false  image  is  tilted  to  the  patient's  right 
{Fig.  42,  6). 

The  distance  between  the  images  becomes  greater  as  the  object 
is  moved  in  the  direction  of  the  action  of  the  paralysed  muscles. 

Vertigo. — Diplopia  causes  considerable  embarrassment  to  the 
patient  while  walking.  On  ascending  a  stair,  for  instance,  he 
sees  two  steps  for  every  one,  and  not  knowing  upon  which  to 
place  his  foot  becomes  confused  and  stumbles.  Perception  of 
distance  is  defective,  and  the  patient  becomes  confused  on  en- 
deavouring to  grasp  objects.  This  constant  confusion  causes 
great  fatigue,  vertigo,  and  sometimes  vomiting.  These  symptoms 
disappear  in  great  part  when  the  distorted  eye  is  closed. 

Compensatory  Attitudes. — The  patient  instinctively  neu- 
tralises the  perception  of  double  images  by  placing  the  head  in 
such  an  attitude  that  the  paralysed  muscle  does  not  require  to 
act.  The  attitude  assumed  by  the  head  is  necessarily  different 
for  each  muscle  paralysed. 

Secondary  Deviation  of  the  Sound  Eye. — This  condition  has 
already  been  described  (§  92). 

False  Projection. — When  a  person  looks  at  an  object  with  one 
eye  only,  a  judgment  of  its  position  in  space  is  formed  by  the 
sense  of  effort  made  to  fix  the  object.  If  a  patient  with  paralysis 
of  the  external  rectus  of  the  left  eye  be  asked  to  touch  an  object 
coming  before  him  from  the  left  or  paralysed  side,  he  misses  it 
by  carrying  his  finger  too  far  to  the  left,  or  to  the  side  of  the 
object  corresponding  to  that  of  the  paralysed  muscle.  The  diffi- 
culty of  immediately  recognising  the  position  of  objects  in  space, 
called  false  projection,  is  caused  by  the  fact  that  it  is  necessary 


DISEASES  OF  THE  MOTOR  CRANIAL  NERVES.  437 

to  make  an  increased  effort  with  the  affected  eye,  so  that  the 
amount  of  rotation  is  over  estimated;  hence  an  erroneous 
judgment  of  the  position  of  the  body  in  space  is  formed. 

Secondary  contraction  of  the  antagonistic  muscles  often 
occurs,  which  increases  the  extent  of  the  deviation,  and  aug- 
ments the  distance  of  the  double  images  from  one  another. 

§  232.   PARALYSIS  OF  PARTICULAR  OCULAR  MUSCLES. 

(1)  Goinfiplete  'paralysis  of  the  oculo-motorius  gives  rise  to 
drooping  of  the  upper  eyelid,  or  ptosis,  drawing  downwards 
and  outwards  of  the  eyeball  by  the  action  of  the  external 
rectus  and  superior  oblique  or  divergent  strabismus,  dilata- 
tion and  immobility  of  the  pupil,  and  impairment  of  the  power 
of  accommodation.  Every  effort  to  move  the  eye  in  any 
direction  causes  it  to  rotate  downwards  and  outwards,  and  it 
gradually  becomes  fixed  in  this  position  by  the  secondary  con- 
traction of  the  external  rectus  and  superior  oblique.  Double 
images  appear  almost  over  the  whole  field  of  vision,  and  fixation 
is  only  possible  in  a  downward  and  outward  direction.  Secondary 
deviations  of  the  healthy  eye  take  place  in  all  directions  except 
in  that  towards  the  affected  eye.  Almost  all  the  recti  being 
paralysed,  the  eye  is  frequently  protruded,  giving  rise  to  the 
appearance  called  paralytic  exophthalmos. 

False  projection  of  the  field  of  vision  occurs  in  every  direc- 
tion towards  which  futile  efforts  at  fixation  are  made.  The 
false  image  is  to  the  patient's  right  when  the  left  eye  is  affected, 
and  when  the  object  is  in  the  horizontal  position,  the  two  images 
are  on  a  level ;  the  false  appears  below  the  true  image  when 
the  object  is  below,  and  above  it  when  the  object  is  above  the 
horizontal  line.  The  compensatory  attitude  of  the  head  is  a 
very  oblique  position,  backwards  and  towards  the  healthy  side. 
The  disorder  of  the  associated  muscles  of  the  eyelids  already 
described  is  met  with  in  incomplete  paralysis  of  the  third  nerve; 
when  the  paralysis  is  complete  this  disorder  is  obscured  by  the 
presence  of  ptosis. 

(2)  Paralysis  of  the  individual  muscles  of  the  eyeball  supplied 
by  the  oculo-motorius. 
(a)  Paralysis  of  the  superior  rectus  gives  rise  to  distortion, 


438 


DISEASES  OF  THE  MOTOR  CRANIAL  NERVES. 


which  is  called  strabismus  dorsum  vergens.  The  visual  axis 
of  the  affected  eye  is  directed  more  downwards  than  that  of  the 
sound  eye,  and  the  cornea  also  diverges  a  little  outwards  from 
the  unopposed  action  of  the  inferior  oblique.  The  false  is  seen 
above  the  true  image,  the  vertical  distance  between  the  images  in- 
creases according  as  the  eyes  are  directed  upwards  and  outwards, 
and  the  false  image  is  tilted  to  the  patient's  right  when  the  left 
eye  is  affected  {Fig.  42,  3) ;  and,  provided  there  be  no  contraction 
of  the  inferior  rectus,  it  disappears  at  the  horizontal  line.  When 
the  eyes  are  directed  downwards,  objects  are  seen  single,  and  the 
head  is  thrown  back,  so  as  to  counteract  the  paralysis. 

(6)  Paralysis  of  the  internal  rectus  gives  rise  to  strabismus 
divergens.     The  power  of  rotating  the  eye  inwards  is  impaired 

Fig.  42. 


Tig.  42  (after  Bristow). — In  the  above  diagram  the  thick  cross  represents  the 
true  image,  the  thin  cross  the  false  iviage.  The  left  eye  is  supposed  to  be 
affected  in  all  of  them. 


DISEASES  OF  THE  MOTOR  CRANIAL  NERVES.  439 

or  lost,  and  when  the  paralysis  is  complete  the  eye  cannot  be 
moved  beyond  the  median  line,  and  the  axis  of  vision  is  inclined 
outwards.  The  images  are  on  the  same  plane,  vertical  and 
parallel,  the  false  one  is  to  the  patient's  right  when  the  left  eye 
is  affected  {Fig.  42,  1),  and  the  lateral  distance  between  the 
images  increases  with  the  movement  of  the  object  towards  the 
sound  side.  There  is  secondary  deviation  of  the  unaffected  eye 
outwards,  and  in  fixing  an  object  the  head  is  turned  towards  the 
healthy  side. 

(c)  Paralysis  of  the  inferior  rectus  causes  squint,  which  is 
called  strabismus  sursum  vergens.  The  symptoms  are  exactly 
the  inverse  of  those  caused  by  paralysis  of  the  superior  rectus. 
The  affected  eye  is  directed  upwards,  and  slightly  outwards.  The 
false  is  below  the  true  image,  and  tilted  to  the  patient's  left  when 
the  left  eye  is  affected  (Fig.  42,  5).  Diplopia  only  occurs  when 
the  eye  is  directed  downwards,  and  double  vision  is  troublesome 
whenever  the  line  of  vision  is  lowered,  as  in  walking  and  in  all 
kinds  of  handiwork.  When  objects  are  held  above  the  horizontal 
line  the  patient  can  see  distinctly. 

(d)  Paralysis  of  the  inferior  oblique  is  rare  as  an  isolated 
affection,  and  when  it  is  associated  with  general  paralysis  of  the 
third  nerve  its  diagnosis  is  almost  impossible.  The  affected  eye 
is  turned  slightly  downwards  and  inwards,  double  images  are 
observed  when  the  eyes  are  directed  above  the  horizontal  line, 
the  false  is  above  the  true  image,  and  tilted  to  the  patient's  left 
when  the  left  eye  is  affected  {Fig.  42,  4).  The  double  images 
are  scarcely  perceptible  in  the  horizontal  line,  and  disappear 
when  the  eyes  are  directed  downwards.  According  as  the  object 
is  carried  upwards  and  outwards  the  images  become  more  and 
more  separated,  both  vertically  and  laterally,  and  the  tilting  of 
the  false  image  becomes  more  pronounced.  On  fixation  in  the 
median  plane  there  is  a  false  projection  of  the  field  of  vision 
upwards  and  slightly  outwards,  and  the  head  is  thrown  back- 
wards, and  the  chin  turned  a  little  towards  the  healthy  side,  so 
that  the  lower  and  outer  segment  of  the  field  of  vision  is  chiefiy 
brought  into  use.  Ptosis  and  mydriasis  frequently  co-exist  with 
paralysis  of  the  inferior  oblique. 

(3)  Paralysis  of  the  Trochlear  Nerve. — The  fourth  or  trochlear 
nerve  supplies  the  superior  oblique  muscle,  and  it  may  be  para- 


440      DISEASES  OF  THE  MOTOK  CRANIAL  NERVES. 

lysed  separately,  especially  in  syphilis,  or  in  connection  with 
paralysis  of  the  sixth  nerve.  Double  images  appear  when 
the  eyes  are  directed  downwards,  and  they  become  more  and 
more  separated  both  vertically  and  laterally,  according  as  the 
object  is  carried  downwards  and  outwards,  while  they  become 
more  closely  approximated  as  the  object  is  moved  upwards.  The 
double  images  are  vertically  superimposed,  the  false  image  being 
the  lower  of  the  two,  and  tilted  to  the  patient's  right  when  the 
left  eye  is  affected  {Fig.  42,  6).  The  image  of  the  affected 
eye  appears  more  remote  than  that  of  the  healthy  one.  The 
secondary  deviation  is  usually  directed  straight  downwards. 
There,  is  false  projection  of  the  field  of  vision  downwards  and  a 
little  outwards,  and  the  head  is  inclined  forwards  and  turned 
towards  the  healthy  side.  The  feeling  of  giddiness  is  often  well 
marked.  When  paralytic  contraction  of  the  inferior  oblique 
exists  the  deviation  and  diplopia  extend  more  and  more  into  the 
upper  half  of  the  field  of  vision. 

(4)  Paralysis  of  the  abducens  nerve  tauses  strabismus  con- 
vergens.  The  external  rectus  alone  is  paralysed  in  this  affection. 
If  the  paralysis  is  complete,  the  eye  cannot  be  rotated  outwards 
beyond  the  middle  line.  Double  images  are  seen  when  the 
eyes  are  turned  in  the  horizontal  line  and  to  the  paralysed  side, 
the  distance  between  them  increases  according  as  the  object 
is  moved  to  that  side,  the  images  are  vertical,  and  the  false  one 
is  to  the  left  of  the  patient  when  the  left  eye  is  affected  {Fig. 
42,  2).  Secondary  deviation  occurs  towards  the  inner  side,  there 
is  false  projection  of  the  field  of  vision  towards  the  outer  side, 
and  the  head  is  turned  towards  the  affected  side.  The  feeling 
of  giddiness  is  severe,  and  may  be  accompanied  by  nausea  and 
vomiting.  Paralysis  of  the  sixth  nerve  may  occur  as  an  isolated 
affection  when  due  to  rheumatism.  It  is  sometimes  bilateral  in 
tabes  dorsalis,  in  tumour  of  the  lower  end  of  the  pons,  or  after 
acute  cerebral  meningitis.  It  has  been  shown  by  Graux  that 
lesion  of  the  nucleus  of  the  sixth  nerve  gives  rise  to  paralysis  of 
the  external  rectus  on  the  same  side  as  the  lesion,  and  of  the 
internal  rectus  of  the  opposite  side,  thus  causing  a  conjugate 
deviation  of  the  eyes  which  is  directed  away  from  the  side  of 
the  lesion. 

Course  and  Duration. — Paralysis  of  one  or  more  of  the  ocular 


DISEASES   OF   THE  MOTOR  CRANIAL  NERVES.  441 

muscles  sometimes  supervenes  suddenly,  appearing  in  the  course 
of  a  night,  as  in  the  rheumatic  and  apoplectic  varieties.  At 
other  times  it  develops  more  slowly  and  gradually,  as  in 
syphilis,  neuritis,  and  chronic  disease  of  the  central  nervous 
system.  When  the  paralysis  has  reached  a  certain  degree  or 
becomes  complete,  the  symptoms  may  remain  stationary  for  a 
variable  period ;  but  after  a  time  secondary  contractures  occur 
which  render  the  symptoms  more  marked,  and  may  considerably 
retard  or  prevent  complete  recovery. 

The  duration  of  paralysis  of  the  ocular  muscles  is  very  vari- 
able. Rheumatic  paralyses  rarely  last  beyond  a  few  weeks. 
Syphilitic  paralyses  may  last  for  months  or  years  and  yet 
recover,  and  the  same  is  true  of  many  central  paralyses.  Many 
cases  are  of  course  quite  incurable. 

§  233.  Diagnosis. — In  complicated  cases,  where  several  muscles 
of  one  or  both  eyes  are  affected,  the  diagnosis  becomes  difficult, 
and  the  reader  must  be  referred  to  special  treatises. 

The  nature  of  the  primary  lesion  must  be  determined  by  a 
thorough  investigation  of  all  the  circumstances  of  the  case.  In 
obscure  cases  care  should  be  taken  to  examine  closely  for  any 
trace  of  syphilis ;  while  the  connection  between  tabes  dorsalis 
and  ocular  paralysis  should  never  be  forgotten. 

With  respect  to  the  locality  of  the  lesion,  it  must  first  be 
determined  whether  the  paralysis  is  of  centric  or  peripheral 
origin.  Disease  of  the  cortex  or  hemispheres  of  the  brain  is 
more  liable  to  cause  conjugate  deviation  of  the  eyes  than  either 
spasm  or  paralysis  of  one  or  more  of  the  muscles  of  one  eyeball. 
But  we  are  more  concerned  at  present  with  the  diagnosis  of  the 
localisation  of  the  lesion,  when  it  is  situated  anywhere  between 
the  origins  of  the  nerves  in  the  nuclei  of  the  pons  or  crura 
cerebri  and  their  terminations  in  the  muscles.  Isolated  paralysis 
of  one  of  the  branches  of  the  third  nerve  is  likely  to  be  caused 
by  a  neuritis  of  the  branch  in  its  course  through  the  orbit, 
except  when  the  paralysis  is  a  symptom  of  locomotor  ataxia. 
A  new  growth  in  the  orbit  gives  rise,  when  it  attains  a  certain 
size,  to  blindness,  retro-bulbar  neuritis  or  perineuritis,  paralysis 
of  iall  the  ocular  motor  nerves,  protrusion  and  Jixity  of  the  globe. 
A  small  tumour  within  the  skull  and  situated  near  to  the  optic 


442 


DISEASES   OF  THE  MOTOK   CRANIAL   NERVES. 


foramen,  gives  rise  to  blindness,  descending  neuritis,  and  sub- 
sequent atrophy  of  the  optic  nerve,  paralysis  of  all  the  ocular 
motor  nerves,  and  paralytic  exophthalmos,  in  which  there  is 
great  mobility  of  the  eyeball.  If  the  tumour  extend  further 
back  over  the  cavernous  sinus  it  is  liable  to  implicate  the  optic 
tract  of  the  same  side,  and  then  there  will  be,  in  addition  to 
the  other  symptoms,  temporal  hemianopsia  of  the  opposite  eye. 
Tumour  or  abscess  in  the  interpeduncular  space  may  cause 
paralysis  of  all  the  branches  of  both  the  third  nerves  {Fig.  43, 
3  and  3'),  and  may  at  the  same  time  cause  paralysis  of  one 
half  or  of  both  sides  of  the  body  by  interference  with  one 
or  both  pyramidal  tracts  (Fig.  43,  p  and  p').  A  lesion  of 
one  of  the  peduncles  of  the  cerebrum  produces  paralysis  of 
the  third  nerve  on  the  same  side,  and  paralysis  of  the  limbs 

Fig.  43. 


Zif. 


/»y 


Fig.  43.  Crura  Cerebri. — Transverse  Section  of  the  Crura  Cerebri  on  a  level  with 
the  anterior  pair  of  the  Corpora  Quadrigemina :  from  a  nine-months  human 
embryo.  The  dark  portions  represent  Medullated  Fibres,  s.  Aqueduct  of 
Sylvius ;  q,  g',  Anterior  pair  of  Corpora  Quadrigemina ;  />/,  p/,  Fasciculi  of 
Medullated  Fibres  proceeding  to  the  anterior  pair  of  Corpora  Quadrigemina ; 
L,  L',  Posterior  Longitudinal  Fasciculi ;  V,  V,  portions  of  these  Fasciculi 
which  join  the  posterior  commissure  of  the  third  ventricle  ;  g,  </,  External 
Geniculate  Bodies  ;  a/,  of,  Anterior  portion  of  Fillet ;  n,  n',  Substantia  Nigra ; 
R,  E.',  Red  Nuclei ;  p,  p',  Pyramidal  Tract ;  c,  c',  Crustse ;  3,  3',  Third  pair  of 
Nerves  ;  x,  Decussation  in  front  of  the  Aqueduct  of  Sylvius,  which  is  part  of 
the  interlacement  of  the  Tegmentum. 


DISEASES  OF   THE  MOTOR  CRANIAL   NERVES.  443 

on  the  opposite  side  of  the  body,  the  latter  being  caused  by 
injury  of  the  pyramidal  tract.  A  circumscribed  lesion  of  the 
upper  and  outer  part  of  the  crus  may  cause  isolated  paralysis  of 
the  fourth  nerve  of  the  same  side,  A  circumscribed  lesion  in 
the  lateral  half  of  the  inferior  posterior  portion  of  the  pons  may 
cause  isolated  paralysis  of  the  sixth  nerve  of  the  same  side ;  if 
the  lesion  extend  across  the  median  raphd  to  the  other  lateral 
half,  it  causes  paralysis  of  both  sixth  nerves ;  but  if  it  extend 
laterally  on  the  same  side,  it  will  cause  paralysis  of  the  sixth 
and  seventh  and  sometimes  also  of  the  eighth  nerves  on  the 
same  side.  A  lesion  in  this  position  injures  the  transverse  fibres 
coming  from  the  cerebellum  to  the  pons,  and  consequently  the 
paralysis  of  the  cranial  nerves  is  generally  associated  with  a 
staggering  gait,  the  tendency  to  fall  being  towards  the  side  of 
the  lesion.  It  ought  to  be  remembered  that  lesion  of  the  nucleus 
of  the  sixth  nerve  gives  rise  to  a  conjugate  deviation  directed 
away  from  the  side  of  the  lesion,  and  not  to  simple  internal  squint 
of  the  same  side,  as  is  caused  by  lesion  in  the  course  of  the  nerve 
itself.     This  subject  will  be  discussed  more  fully  hereafter. 

§  2.34.  Prognosis. — The  prognosis  chiefly  depends  upon  the 
cause  of  the  affection.  It  is  favourable  in  rheumatic  cases,  and 
even  traumatic  cases  often  recover.  The  prognosis  is  doubtful 
in  syphilis,  since  many  cases  do  not  yield  to  treatment.  The 
prognosis  is  good  in  the  early  stages  of  tabes  dorsalis,  inasmuch 
as  the  ocular  paralysis  frequently  disappears  spontaneously, 
although  it  may  recur.  In  central  affections  generally  the 
prognosis  is  grave.  When  galvanic  treatment  is  followed  by 
prompt  improvement  the  prognosis  is  favourable. 

§  235.  Treatment. — The  cause  of  the  paralysis  must  first  be 
ascertained,  and  if  possible  removed,  and  more  especially  in 
cases  of  rheumatic  or  syphilitic  origin.  Electricity  is  the  most 
important  of  the  direct  remedies,  and  both  the  galvanic  and 
faradic  currents  may  each  be  advantageously  employed  in  certain 
cases.  The  galvanic  current  is  the  most  generally  useful  form, 
and  a  stabile  application  should  be  made  transversely  through 
the  temples  or  through  the  mastoid  processes,  and  also  longi- 
tudinally from  the  eye  to  the  neck.     In  order  to  act  directly  on 


444  DISEASES  OF  THE  MOTOR  CRANIAL   NERVES. 

the  paralysed  muscles  the  anode  may  be  applied  to  the  neck, 
and  the  cathode  should  glide  over  the  closed  eyelids,  especially 
over  those  points  which  correspond  to  the  paralysed  muscles. 
The  currents  used  should  not  be  stronger  than  may  be  sufficient 
to  produce  distinct  contractions  of  the  facial  muscles  when  the 
face  is  stroked  with  the  cathode.  The  application  should  not 
exceed  two  or  three  minutes,  and  care  should  be  taken  to  avoid 
interruptions  and  reversals.  In  favourable  cases  improvement 
begins  very  soon  under  galvanic  treatment,  although  in  some 
cases  the  treatment  must  be  pursued  many  months  before  im- 
provement occurs.  Galvanisation  of  the  sympathetic  appears  to 
be  of  use  at  times. 

Direct  faradic  stimulation  in  the  vicinity  of  the  attachments 
of  the  affected  muscles  may  be  adopted  either  by  means  of  a 
small  sponge  electrode  applied  to  the  closed  lids,  or  by  means  of 
a  fine  brush  acting  as  an  electrode  and  applied  to  the  conjunctiva. 
Weak  and  medium  currents  must  be  used,  and  for  a  short  time 
only. 

Of  other  remedies  iodide  of  potassium  is  the  most  generally 
useful,  since  many  cases  of  unknown  origin,  but  which  are  not 
necessarily  syphilitic,  improve  under  its  administration.  Sub- 
cutaneous injection  of  strychnia  has  been  found  useful. 

Gymnastics  for  the  ocular  muscles  has  been  found  of  use  in 
the  slighter  forms  of  the  affection.  These  consist  in  exercising 
the  enfeebled  muscles  by  forced  lateral  movements,  and  by 
stereoscopic  exercises  with  the  view  of  suppressing  the  second 
image. 

The  fusion  of  the  double  images  may  be  greatly  aided  by 
means  of  prisms.  A  pair  of  spectacles  with  one  dull  glass  for 
the  affected  eye  acts  as  a  palliative  remedy  for  the  discomfort 
arising  from  the  double  images.  If  the  affection  resist  all 
ordinary  treatment,  the  propriety  of  resorting  to  operative  pro- 
cedure must  be  determined  by  the  ophthalmic  surgeon. 

(B)  Internal  Muscles  of  the  Eye. 

§  236.  The  internal  muscles  of  the  eye  are  (1)  the  ciliary  muscle,  and 
(2)  the  muscles  of  the  iris. 

(1)  The  Ciliary  Muscle. — The  ciliary  muscle  arises  by  a  thin  tendon 
from  the  fore  part  of  the  sclerotic,  close  to  the  cornea,  and  its  fibres  are 


DISEASES   OF  THE  MOTOR  CRANIAL   NERVES.  445 

directed  backwards  to  be  inserted  into  the  anterior  margin  and  part  of  the 
outer  surface  of  the  choroid.  The  fibres  next  the  iris  pass  into  a  ring  of 
fibres  which  have  a  circular  course  around  the  insertion  of  the  iris,  and 
form  the  circular  ciliary  muscle  of  MiiUer.  When  the  eye  is  at  rest  the 
elasticity  of  the  suspensory  ligament  keeps  the  lens  tense  and  its  anterior 
surface  flattened.  When,  however,  the  ciliary  muscle  contracts  the  sus- 
pensory ligament  becomes  relaxed ;  this  removes  the  tension  from  the  lens, 
and  by  its  own  inherent  elasticity  its  anterior  svuface  becomes  more  convex. 
The  normal  eye  is  adjusted  when  at  rest  for  infinite  distances,  and  the  focal 
point  then  lies  on  the  retina,  and  were  no  mechanism  for  accommodation 
in  existence  the  focal  points  for  medium  and  near  distances  would  faU 
behind  the  retina,  and  aU  objects  at  these  distances  would  be  blurred.  But 
the  increasing  convexity  of  the  lens,  as  objects  approach  the  eye,  maintains 
the  focal  point  always  on  the  retina,  until  they  approach  the  eye  so  near 
that  further  accommodation  is  impossible,  which  is  usiially  a  distance  of 
about  ten  inches  from  the  eye.  But  as  the  lens  becomes  more  convex  its 
spherical  aberration  increases,  and  consequently  a  greater  number  of  the 
marginal  rays  require  to  be  cut  ofi"  in  order  to  have  distinct  vision.  This 
is  effected  in  the  eye  by  a  simultaneous  contraction  of  the  pupil  taking 
place  along  with  efforts  at  accommodation.  This  leads  lis  to  speak  of  the 
muscles  of  the  iris. 

(2)  Muscles  of  the  Iris. — The  size  of  the  pupil  is  regulated  by  means  of 
two  antagonistic  sets  of  musciilar  fibres  in  the  iris,  the  sphincter  and  dilator 
fibres.  The  sphincter  is  a  layer  of  muscular  fibres  circularly  disposed 
around  the  pupil ;  while  the  dilator  fibres  have  a  radiate  arrangement,  their 
inner  extremities  being  attached  to  the  sphincter  or  margin  of  the  pupil, 
and  their  outer  extremities  to  the  sclerotic  coat  at  its  point  of  junction 
with  the  cornea. 

Size  of  the  Pupil. — Various  means  for  estimating  the  size  of  the  pupil 
have  been  proposed,  but  probably  the  most  efficient  pupilometer  is  the  one 
recommended  by  Mr.  J.  Hutchinson.^  It  consists  of  the  perforated  metal 
plate  used  to  measure  bougies ;  the  plate  is  placed  upon  the  patient's  cheek, 
just  below  the  eye,  and  turned  until  the  hole  which  corresponds  in  size 
with  the  pupil  is  foimd  and  noted.  Under  normal  conditions  the  pupil  is 
maintained  midway  between  contraction  and  dilatation  by  the  normal 
tonus  of  the  sphincter  and  dilator  muscles,  the  size  differing  considerably 
in  different  individuals,  and  varying  from  3  to  5  mm.  {Fig.  44,  4  to  8).  It 
is  important  to  remember  that  the  normal  size  of  the  pupil  is  maintained 
when  both  muscles  have  lost  their  normal  tonus  by  paralysis.  Contraction 
of  the  pupil,  or  myosis,  as  it  is  called,  may  be  caused  by  spasm  of  the 
sphincter  (spasmodic  myosis)  or  paralysis  of  the  dilator  (paralytic  myosis). 
In  these  conditions  the  pupil  reaches  a  medium  degree  of  contraction,  and 
may  vary  in  diameter  from  2  to  3  mm.  {Fig.  4A,  2  to  4).  When,  however, 
spasm  of  the  sphincter  is  associated  with  paralysis  of  the  dilator  (combined 

1  Hutchinson  (J.).  "Notes  on  the  symptom-significance  of  different  states  of 
the  pupil."    Brain,  Vol.  I.,  1879,  pp.  1, 155,  and  454. 


446  DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 

spasmodic  and  paralytic  myosis)  a  maximum  contraction  ensues,  and  the 
diameter  of  the  pupil  varies  from  |  to  2  mm.  {Fig.  44,  0  to  2).  DUatation 
of  the  pupil,  or  mydriasis,  as  it  is  called,  may  be  caused  by  spasm  of 
the  dilator  (spasmodic  mydriasis)  or  paralysis  of  the  sphincter  (paralytic 
mydriasis),  and  in  both  of  these  conditions  the  pupil  reaches  a  medium 
degree  of  dilatation,  its  diameter  varying  from  5  to  7  mm.  {Fig.  44,  8  to  14), 
But  when  spasm  of  the  dilator  is  associated  with  i^aralysis  of  the  sphincter 
(combined  spasmodic  and  paralytic  mydriasis)  a  maximum  dilatation  of 
the  pupil  ensues,  and  its  diameter  may  reach  the  size  of  from  7  to  8  mm. 
{Fig.  44,  14  to  17).  These  figm-es  are  of  course  only  approximate,  and  it 
is  important  to  remember  that  the  pupil  becomes  smaller  with  age  in  the 
absence  of  any  special  disease. 

§  237.  Movements  of  the  Pupil. — The  iris  is  capable  of  undergoing  two 
movements,  the  one  leading  to  contraction  and  the  other  to  dilatation  of  the 
pupil.  In  contraction  of  the  pupil  the  fibres  of  the  sphincter  muscle 
become  shortened,  but  this  shortening  may  be  either  active  or  passive. 
In  active  shortening  the  muscular  fibres  contract  in  response  to  nervous 
stimulation  like  any  other  muscular  fibres,  but  in  passive  shortening  they 
become  contracted  because  the  dilator  fibres  are  paralysed,  and  thus  the 
ends  of  the  fibres  of  the  sphincter  become  approximated  by  means  of  the 
normal  muscular  tonus.  And  if  the  dilator  fibres  are  paralysed  for  a 
prolonged  period  of  time,  the  sphincter  undergoes  permanent  paralytic 
contraction. 

All  that  has  just  been  said  with  regard  to  contraction  of  the  pupil  is 

Fig,  44, 


Fig.  44  (after  HutcMnson).— No.  0  measares  about  one-third  of  a  line  ;  No.  1,  two- 
thirds  of  a  line  ;  No.  2,  a  line  ;  No.  3,  a  line  and  a  quarter ;  No.  4,  a  line  and  a 
half ;  No.  5,  a  line  and  two-thirds ;  No.  6,  nearly  two  lines  ;  No.  7,  two  lines 
full ;  No.  8,  two  lines  and  a  quarter ;  No.  9,  two  lines  and  two-thirds  ;  No.  10, 
three  lines  nearly  ;  No.  11,  three  lines  full ;  No.  12,  three  lines  and  a  quarter ; 
No.  13,  three  lines  and  one4hird ;  No.  14,  three  and  one-half ;  No.  15,  three 
and  two-thirds ;  No.  16,  four  lines ;  No.  17,  four  lines  and  a  half. 


DISEASES  OF  THE  MOTOR  CRANIAL   NERVES.  447 

equally  applicable  to  dilatation  of  it,  which  may  be  caused  either  by 
active  contraction  of  the  dilator  fibres  or  passive  contraction  of  them  from 
paralysis  of  the  sphincter.  By  acting  on  the  nervous  mechanism  of  the  iris 
the  normal  pupil  can  be  made  to  contract  or  dilate  at  pleasure.  The  pupil 
is  thus  said  to  be  movable  or  mobile.  In  certain  morbid  conditions  con- 
traction and  dilatation  of  the  pupil  cannot  be  obtained,  and  then  the  pupil 
is  said  to  be  immovable  or  immobile,  and  when  the  movements  of  the  iris 
are  imperfect  and  slow  in  taking  place  the  pupil  is  said  to  be  shoggish. 
Labile  and  stabile  pupils  are  other  terms  which  have  been  used  to  indicate 
a  movable  and  immovable  pupil  respectively.  There  may  also  be  a  partial 
immobility/  of  the  pupil  in  which  it  fails  to  respond  to  certain  stimuH,  while 
it  contracts  or  dilates  readily  to  others.  Complete  imTnobility  of  the  pupil 
is  possible  under  the  following  circumstances  :  (1)  paralysis  of  both  the 
sphincter  and  dilator  muscles,  (2)  paralysis  of  the  sphincter  combined 
with  spasm  of  the  dilator,  and  (3)  paralysis  of  the  dilator  combined  with 
spasm  of  the  sphincter.  In  the  first  of  these  the  size  of  the  pupil  is  normal, 
in  the  second  it  reaches  its  highest  degree  of  dilatation,  and  in  the  third 
it  reaches  its  highest  degree  of  contraction. 

A  normal  pupil  is,  as  we  have  seen,  capable  of  being  made  to  contract 
or  dilate  by  the  action  of  various  stimuli ;  but  when  the  dilator  muscle  is 
paralysed  the  pupil  can  be  made  to  contract  further,  but  not  to  dilate,  and 
when  the  sphincter  is  paralysed  it  can  be  made  to  dilate  further,  but  not  to 
contract.  Other  forms  of  immobility  of  the  pupil  will  be  best  imderstood 
after  we  have  described  the  nervous  mechanism  which  regulates  the  move- 
ments of  the  iris. 

§  238.  Nervous  Mechanism  of  the  Iris  and  Ciliary  Muscle. — The  nervous 
mechanism  which  presides  over  the  internal  movements  of  the  eye  con- 
sists of  nerve  centres  and  their  connections  with  one  another  and  with 
the  muscles.  Two  motor  centres  exist  in  the  spinal  axis ;  one  of  them 
(Fig.  45,  C)  is  connected  with  the  nucleus  of  origin  of  the  third  nerve,  and 
is  situated  beneath  the  floor  of  the  aqueduct  of  Sylvius,^  while  the  other 
{Fiff.  45,  D)  is  most  probably  situated  in  the  medulla  oblongata.  The  first 
of  these  is  connected  with  the  ciliary  muscle  and  the  sphincter  of  the  iris  by 
means  of  efferent  fibres  {Fig.  45,  H),  which  are  contained  in  the  third  nerve, 
and  the  second  is  connected  with  the  dilator  of  the  iris  by  means  of  fibres 
which  descend  in  the  pons,  medulla  oblongata,  and  spinal  cord  to  reach  the 
last  cervical  and  first  dorsal  nerves  (Fig.  45,  K  and  L),  and  ultimately  find 
their  way  to  the  iris  through  the  cervical  sympathetic  {Fig.  45,  I),  caver- 
nous plexus,  lenticular  ganglion,  and  ciliary  nerves.  It  is  not  improbable 
but  that  some  of  the  dilator  fibres  find  their  way  to  the  eyeball  in  other 
ways  than  through  the  cervical  sympathetic.^     It  is  at  least  proved  that  in 

1  Adamuck.  "Ueber  die  Innervation  der  Augenbewegungen."  Centralbl.  f.  d. 
med.  Wissensch.,  Bd,  VIII.,  1870,  p.  65. 

^  Vulpian.  "  Note  de  relation  a  I'influence  de  I'extirpation  du  ganglion  cervical 
superieur  sur  lea  mouvements  de  I'iris."  Arch,  de  physiologie,  Tome  I.,  Serie  II., 
1874,  p.  177. 


448 


DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 


rabbits  and  other  animals  section  of  the  trigeminus  at  the  base  of  the  skull 
causes  a  primary  dilatation  to  be  soon  followed  by  contraction  of  the  pupil. 
Some  authors^  believe  that  dilator  fibres  originate  in  the  Gasserian  gang- 
lion, but  it  is  much  more  likely  that  these  fibres  are  derived  from  the 
carotid,  tympanic,  or  some  of  the  neighbouring  plexuses  of  the  sympathetic. 
The  spinal  motor  centres  of  the  iris  are  also  connected  with  the  periphery 
by  means  of  afferent  fibres,  some  of  these  being  sensory  and  others  reflex. 
The  fifth  nerve  contains  the  nerves  of  common  sensation  distributed  to  the 
eyeball ;  these  begin  in  the  eyeball,  pass  along  the  fifth  nerve  to  the  pons, 
and  ascend  through  the  posterior  part  of  the  internal  capsule  to  reach  the 
cortex.  Other  fibres  take  their  origin  in  the  cornea  and  iris,  and  become 
connected  by  a  reflex  loop  with  efferent  fibres  to  the  sphincter,  but  the 
connection  between  them  is  most  probably  established  in  the  lenticular 
ganghon.  The  dilator  centre  appears  to  be  connected  directly  or  in- 
directly with  the  afferent  nerves  of  the  body  generally  {Fig.  45,  M  ISi  0), 
so  that  any  strong  irritation  of  the  skin  or  mucous  membranes  causes 
reflex  dilatation  of  the  pupil.  The  optic  nerve  contains  afferent  fibres 
which  conduct  impulses  communicated  to  the  retina  by  the  stimulus 
of  light  inwards  to  the  corpora  quadrigemina  {Fig.  45,  G  to  B),  and  up- 

FlG.  45. 


Pia.  45  (after  Erb). — A  A,  psychical  impression;  B,  centrum  optici;  C,  oculo- 
motor centre ;  D,  dilator  centre  (spinal) ;  E,  iris ;  G,  optic  nerve  ;  H,  oculo- 
motor (sphincter) ;  I,  sympathetic  (dilator)  ;  K,  L,  anterior  roots  ;  M  N  0,  pos- 
terior roots ;  A,  seat  of  lesion  causing  reflex  pupillary  immobility  ;  *,  probable 
seat  of  lesion  causing  myosis. 

»  Guttraann.    "Zur  Innervation  der  Iris,"     Centralbl.  f.  d.  med.  Wissenech.. 
Bd.  II.,  1864,  p.  598. 


DISEASES   OF  THE  MOTOR  CRANIAL   NERVES.  449 

wards  to  the  cortex,  where  they  become  the  correlatives  of  a  sensation  of 
light.  The  optic  nerves  and  tracts  also  contain  reflex  afferent  fibres  which 
bend  down  in  the  corpora  quadrigemina  to  become  connected  by  means  of 
a  reflex  loop  with  that  portion  of  the  nucleus  of  the  third  nerve  which 
is  connected  with  the  sphincter  of  the  iris  {Fig.  45,  B  to  C).  These 
afferent  fibres  conduct  impulses  caused  by  the  stimulus  of  light  on  the 
retina  inwards  to  the  corpora  quadrigemina,  and  thence  to  the  nucleus  of 
the  third  nerve,  whence  they  become  reflected  outwards  to  the  sphincter  of 
the  iris.  In  addition  to  the  centres  in  the  spinal  axis,  two  motor  centres 
exist  in  the  cortex  of  the  brain  {Fig.  45,  A,  A).  One  of  these,  situated 
probably  in  the  angular  gyrus,  is  connected  with  the  nucleus  of  the 
third  nerve  by  means  of  centrifugal  fibres.  These  fibres  are,  however, 
connected  with  the  nucleus  of  the  third  nerve  in  such  a  way  that  the  same 
impulses  give  rise  to  a  contraction  of  the  internal  recti  muscles,  the  ciliary 
muscle,  and  the  sphincter  of  the  iris,  thus  simultaneously  converging  the 
eyes,  adjusting  the  lens  to  short  distances,  and  contracting  the  iris.  The 
second  cortical  centre  is  probably  situated  in  the  posterior  part  of  the  first 
and  second  frontal  convolutions — No.  12  in  Ferrier's  diagram  of  the  cor- 
tical motor  centres.  It  is  connected  by  means  of  centrifugal  fibres,  whose 
course  are  not  well  known,  with  the  dilator  centre  of  the  spinal  axis,  and  it 
is  by  irritation  of  this  cortical  centre  that  the  pupil  becomes  dilated  during 
various  emotional  states.  In  addition  to  the  sensory  and  motor  centres, 
conducting  paths,  and  nerve  fibres  which  have  just  been  described,  the 
blood-vessels  of  the  iris  are  supplied  by  vaso-motor  fibres  for  the  regulation 
of  the  circulation.  These  fibres  appear  to  arise  from  a  separate  centre  in 
the  medulla  oblongata  ;  they  descend  through  the  cervical  portion  of  the 
cord,  hke  the  dilator  fibres,  to  join  the  cervical  sympathetic  and  pass  into 
the  eyeball  by  various  unknown  channels,  but  most  probably  along  with 
the  blood-vessels.  It  is  very  probable  that  these  fibres  take  a  share  in 
producing  slight  alterations  in  the  size  of  the  pupils,  spasm  of  them 
causing  a  certain  degree  of  dilatation,  and  relaxation  a  certain  degree  of 
contraction,  of  the  pupils. 

§  239.  Summary  of  the  Conditions  under  which  the  Movements 
of  the  Pupil  occur. 

(1)  Contraction  to  the  Stimulus  of  Light. — When  light  falls  upon  the 
back  of  the  eye  the  pupil  contracts.  The  impulses  are  conveyed  through 
the  optic  nerves  and  tracts  to  the  corpora  quadrigemina,  are  thence  con- 
ducted by  means  of  a  reflex  loop  to  the  nucleus  of  origin  of  the  third 
nerve,  and  from  it  reflected  outwards  to  the  sphincter  of  the  iris.  Inter- 
ruption of  the  reflex  arc  in  any  part  of  its  com-se  will  arrest  this  movement. 
It  is  important,  however,  to  remember  that  this  reflex  mechanism  is 
bilaterally  associated,  so  that  when  light  is  admitted  to  one  eye  both 
pupils  contract.  And  in  cases  in  which  the  optic  nerve  of  one  side  is 
atrophied  and  the  other  healthy,  when  Ught  is  allowed  to  fall  upon  the  blind 
VOL.  I.  D  D 


450      DISEASES  OF  THE  MOTOR  CRANIAL  NERVES. 

eye  the  pupils  do  not  contract,  but  when  light  falls  upon  the  normal  eye 
both  pupils  contract.  This  reflex  contraction  is  lost  in  paralysis  of  the 
third  nerve  ;  it  is  also  lost  in  other  diseases,  such  as  locomotor  ataxy,  in 
which  both  the  afierent  and  efferent  fibres  of  the  reflex  arc  are  normal, 
and  consequently  the  arrest  of  fimction  miist  take  place  in  the  loop  which 
connects  the  two  sets  of  fibres  {Fig.  45,  a). 

(2)  Contraction  to  Local  Irritation. — It  has  been  found  by  Griinhagen^ 
that  chemical  irritation  and  mechanical  injuries  of  the  cornea  cause  con- 
traction of  the  pupil,  and  Bernard  observed  it  to  contract  by  irritation  of 
the  ophthalmic  branch  of  the  fifth  nerve.  It  is  very  probable,  therefore, 
that  the  contraction  of  the  pupil  which  is  observed  in  iritis,  and  other 
diseases  of  the  eyeball,  as  well  as  that  which  occurs  during  operations  on 
the  eye,2  is  produced  in  a  reflex  manner  by  a  local  irritation  of  the  fibres  of 
the  fifth  nerve.  The  course  of  the  reflex  arc  is  not  well  ascertained  ;  some 
think  that  this  reflexion  takes  place  in  the  lenticular  ganghon,  while  others 
believe  that  it  occurs  in  local  ganglia  situated  within  the  eyeball.  The 
reflex  is  not  abohshed  by  separation  of  the  third  nerve  from  its  nucleus  in 
the  crus  cerebri.  After  an  attack  of  iritis  the  pupil,  not  unfrequently, 
remains  permanently  contracted,  but  this  is  due,  not  to  disease  of  the 
nervous  mechanism,  but  to  adhesions  and  structural  changes  in  and  around 
the  muscular  fibres  themselves.  Paralysis  of  the  vaso-motor  fibres  may 
account  for  some  of  the  contraction  of  the  pupil  observed  in  iritis,  but 
the  degree  of  contraction  is  too  great  to  be  thus  fully  explained. 

(3)  Associated  Contraction  to  Accommodation. — During  accommodation 
of  the  eye  to  near  vision  the  pupil  contracts.  This  is,  as  we  have  seen,  an 
associated  movement,  the  impulses  which  cause  it  coming  from  the  cortical 
centre  and  through  the  third  nerve.  Eotation  of  the  eyebaU  inwards  is 
also  accompanied  by  a  contraction  of  the  pupil,  which  is  most  probably  of 
the  same  nature  as  the  associated  contraction  with  accommodation. 

(4)  Dilatation  from  Irritation  of  the  Cilio-Spinal  Centre. — It  has  been 
found  by  Bernard^  and  others  that  dilatation  of  the  pupil  is  caused  by  any 
powerful  irritation  of  sensory  nerves.  The  pupils  are  also  dilated  during 
dyspnoea,  and  as  this  dilatation  does  not  occur  if  the  sympathetics  have 
been  previously  divided,  it  must  be  caused  by  irritation  of  the  dilator 
centre  of  the  ciUo-spinal  region.  The  pupil  also  becomes  enlarged  during 
severe  muscular  efforts ;  this  dilatation  likewise  appears  to  be  caused  by 
irritation  of  the  cilio-spinal  region.  Dilatation  of  the  pupil  occurs  dtudng 
severe  mental  effort  and  various  emotional  states,  and  the  dilator  centre  is 
then  most  probably  stimulated  from  the  cortex  of  the  brain. 

(5)  The  Effects  of  Various  Poisons  on  the  Pupil. — The  poisons  which 
act  on  the  pupil  have  been  named  mydriatics  and  myotics,  according  as 

'  Griinhagen.  Henle  and  Pfeufer's  Zeitschrift  fiir  rat.  med.  Bd.  XXVIII., 
1866,  p.  244;  and  Ibid.,  Bd.  XXIX.,  p.  338. 

""  Graefe  (Von).     Arch.  f.  Ophth.     Bd.  III.,  Abth.  2,  p.  435. 

^  See  Leeser  (J.),  "Die  Pupillarbewegungen  in  physiologischer  und  patholo- 
giacher  Bezfehung. "    Wiesbaden,  1881.    p.  40. 


DISEASES   OF  THE  MOTOR  CRANIAL   NERVES.  451 

they  produce  dilatation  or  contraction  of  the  pupils  respectively.  Atropine 
is  the  best  known  of  the  mydriatics,  although  duboisine,  hyosyamine, 
and  daturine  appear  to  be  equally  efficient.  Atropine  seems  to  act  on  the 
terminal  fibrils  of  the  nerves,  and  probably  also  on  the  local  ganglia  in 
the  iris.  The  most  recent  researches^  point  to  the  conclusion  that  atropine 
acts  upon  the  terminal  fibrils  of  all  the  motor  fibres  of  the  iris,  but  that  it 
has  a  preferential  action  on  the  terminal  filsrils  of  the  third  nerve.  A  very 
small  dose  of  atropine  is  said  to  stimulate  the  terminal  fibrils  of  the  third 
nerve,  and  thus  leads  to  a  moderate  contraction  of  the  pupil.  A  medium 
dose  paralyses  these  fibres  and  at  the  same  time  stimulates  the  terminal 
fibrils  of  the  sympathetic,  and  thus  causes  a  maximum  dilatation  of  the 
pupil.  But  a  large  dose  of  atropine  is  said  to  paralyse  both  sets  of  nerve 
fibres,  and  it  then  causes  the  pupil  to  remain  midway  between  dilatation 
and  contraction.  The  pupil  becomes  somewhat  dilated  during  poisoning 
by  strychnine  and  curara,  but  Schifif  has  found  that  this  dilatation  dis- 
appears when  artificial  respiration  is  resorted  to,  and  he  concluded  that 
these  drugs  only  caused  dilatation  by  inducing  asphyxia,  and  they  con- 
sequently can  only  be  regarded  as  indirect  mydriatics.  Eserine  is  the  best 
known  of  the  direct  myotics,  and  may  be  taken  as  the  type  of  the  others. 
It,  like  atropine,  acts  upon  the  terminal  fibrils  of  the  nerves  of  the  iris ; 
in  small  doses  it  is  said  to  produce  slight  dilatation  of  the  pupil ;  in 
medium  doses  it  paralyses  the  dilator  fibres  and  stimulates  the  sphincter, 
and  thus  produces  a  maximum  contraction ;  but  in  high  doses  it 
paralyses  both  sets  of  fibres,  and  the  pupil  returns  to  a  medium  size. 
Atropine  and  eserine  are  thus  antagonists  in  their  action  on  the  pupil. 
They  are  also  antagonists  in  their  action  on  the  ciliary  muscle,  inasmuch 
as  atropine  paralyses  it  and  accommodates  the  eye  to  distant  vision,  while 
eserine  causes  it  to  contract  and  accommodates  the  eye  to  near  vision. 
Dm'ing  the  production  of  anaesthesia  by  chloroform  the  dilator  centre  is 
first  irritated,  and  the  pupil  becomes  dilated.  As  narcosis  deepens  this 
centre  becomes  more  and  more  paralysed  and  the  pupil  contracts,  and  no 
dilatation  is  now  produced  by  external  irritation.  In  the  next  stage  the 
contractor  centre  is  placed  in  a  state  of  irritation,  and  the  pupil  becomes 
contracted  to  the  size  of  a  pin-point.  If  the  inhalation  is  carried  further, 
this  centre  may  also  become  paralysed,  and  the  pupil  dilates.  Sudden 
dilation  of  the  pupil  after  contraction  indicates  the  greatest  possible 
danger. 

§  240.  Disorders  of  the  Movements  of  the  Internal  Muscles  of 

the  Eye. 

The  disorders  of  the  movements  of  the  internal  muscles  of  the 
eye  may  be  divided  into  those  affecting  (I.)  the  ciliary  muscle, 
and  (II.)  the  muscles  of  the  iris. 

'  Leeser.     Op.  cit.,  p.  71. 


452  DISEASES  OF   THE  MOTOR   CRANIAL  NERVES. 

(I.)  Disorders  of  the  Ciliary  Muscle. 

(1)  Spasm  of  the  ciliary  muscle  accommodates  vision  to  near 
objects  and  renders  the  patient  myopic;  it  is  rare  as  an  idio- 
pathic affection,  but  it  occurs  in  cases  of  hypermetropia  in  young 
persons  who  have  strained  their  eyes  without  using  convex 
glasses,  and  also  in  those  who  make  great  efforts  to  see  small 
objects,  as  watchmakers  and  engravers.  Spasm  of  the  ciliary 
muscle  is  usually  accompanied  by  contracted  pupil  from  asso- 
ciated spasm  of  the  sphincter  of  the  iris,  both  conditions 
being  caused  by  direct  or  indirect  irritation  of  the  third  nerve. 
Spasm  of  accommodation  may  be  artificially  produced  by  various 
pharmaceutical  agents,  such  as  opium.  Calabar  bean,  and  pilocar- 
pine. Graefe  has  observed  spasm  of  the  ciliary  muscle  as  a  reflex 
symptom  of  ophthalmic  and  facial  neuralgia,  and  Galezowski  has 
met  with  it  in  a  case  of  locomotor  ataxy  in  a  patient  affected 
with  myopia. 

(2)  Paralysis  of  the  Ciliary  Muscle  (Gycloplegia). — This 
affection  is  often  complicated  with  mydriasis,  though  it  may 
occur  as  an  independent  affection.  The  patient,  if  not  myopic, 
is  unable  to  focus  small  objects,  or  read  small  print,  and  he 
forms  an  incorrect  estimate  of  the  size  and  distance  of  small 
objects.  This  affection  is  very  common  in  diphtheritic  paralysis, 
and  it  is  generally  present  along  with  paralytic  mydriasis  as  a 
symptom  of  paralysis  of  the  third  nerve.  It  may  result  from 
disease  in  the  short  root  of  the  lenticular  ganglion,  or  in  the 
trunk  of  the  third  nerve,  or  in  the  brain  itself.  Cycloplegia  is 
sometimes  associated  with  paralysis  of  both  the  muscles  of  the 
iris,  and  the  disorder  is  then  called  ophthalmoplegia  interna. 
The  latter  affection  will  be  described  along  with  the  nervous 
diseases  of  the  iris. 

Treatment  must  be  directed  against  the  cause  of  the  affection. 
In  spasm  of  the  muscle  the  accommodation  should  be  paralysed 
by  the  use  of  a  strong  solution  of  atropine  and  the  effect  main- 
tained for  several  weeks,  while  complete  rest  of  the  eyes  is 
enjoined.  If  there  is  no  hypermetropia,  concave  glasses  may  be 
worn  in  order  to  correct  the  temporary  condition  of  myopia 
which  has  been  produced.  In  paralysis  of  the  ciliary  muscle 
the  general  treatment  depends  upon  whether  the  affection  has 


DISEASES   OF   THE  MOTOR  CRANIAL   NERVES.  453 

been  caused  by  diphtheria,  syphilis,  or  rheumatism.  The  local 
treatment  consists  of  the  application  of  a  solution  of  Calabar 
bean  to  the  eye  and  the  use  of  convex  glasses. 

(II.)  Disorders  of  the  Muscles  of  the  Iris. 

Although  our  chief  object  at  present  is  to  describe  the  diseases 
of  the  cranial  nerves,  yet  it  is  impossible  to  understand  fully  the 
disorders  of  the  movements  of  the  iris  without  taking  the  action 
of  the  sympathetic  nerves  of  the  eye  into  account.  Various 
classifications  of  the  nervous  affections  of  the  iris  might  be  made, 
but  we  shall  adopt  the  one  which  will  be  of  the  greatest  use  from 
the  clinical  standpoint.  We  have  already  seen  that  when  the 
normal  eye  is  looking  at  a  distant  object  in  a  diffused  light,  the 
pupil  is  in  a  condition  midway  between  extreme  dilatation  and 
extreme  contraction.  Disease  is  indicated  by  an  undue  contrac- 
tion or  an  undue  dilatation  of  the  pupil,  the  former  condition 
being  named  imyosis,  and  the  latter  mydriasis.  In  addition  to 
the  conditions  just  described  the  pupil  may  be  of  normal  size 
but  completely  immovable,  or  the  muscles  may  be  affected  by 
clonic  spasm,  and  the  iris  is  likewise  liable  to  various  reflex 
derangements,  which  will  have  to  be  considered.  The  disorders 
of  the  movements  of  the  iris  may  therefore  be  divided  into  the 
following  varieties,  namely,  (1)  myosis,  (2)  mydriasis,  (3)  immo- 
bility of  the  pupil  with  normal  size,  (4)  clonic  spasm  of  the 
muscles  of  the  iris,  and  (5)  reflex  disorders  of  the  pupil. 

(1)  Myosis. — Three  forms  of  myosis  may  be  distinguished,, 
namely,  (a)  spastic  or  spasmodio  myosis,  caused  by  spasm  of  the 
sphincter;  (6)  paralytic  myosis,  caused  by  paralysis  of  the 
dilator  fibres  ;  and  (c)  combined  spasmodic  and  paralytic 
myosis,  produced  by  simultaneous  spasm  of  the  sphincter  and 
paralysis  of  the  dilator  muscle.  In  the  first  two  of  these  forms 
the  pupil  is  in  a  medium  degree  of  contraction  and  mobile,  and 
consequently  both  conditions  may  be  comprised  under  the  name 
of  medium  or  labile  Tnyosis.  In  the  last  of  the  three  the  pupil 
is  in  the  highest  degree  of  contraction  and  immobile,  and  it  con- 
sequently may  be  named  maximum  or  stabile  myosis. 

(a)  Spastic  myosis  is,  as  already  stated,  caused  by  spasm  of 
the  sphincter  of  the  iris.  If  there  is  a  high  degree  of  spasm  the 
pupil  does  not  contract  to  the  stimulus  of  light  or  during  efforts 


454  DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 

at  accommodation.  The  pupil  does  not  dilate  by  shading  the 
eyes,  but  a  moderate  dilatation,  unless  prevented  by  adhesions 
or  some  other  cause,  may  be  produced  by  all  excitants  of  the 
dilator  centres  or  fibres,  such  as  a  strong  sensory  impression  upon 
any  part  of  the  body  and  emotional  states.  A  minimum  dilata- 
tion is  readily  produced  by  mydriatics,  and  a  maximum  con- 
traction by  myotics. 

(6)  Paralytic  myosis  is  caused  by  paralysis  of  the  dilator  of 
the  iris,  and  the  pupil  is  in  a  medium  degree  of  contraction.  In 
uncomplicated  cases  of  this  condition  the  pupil  reacts  promptly 
to  the  stimulus  of  light  and  accommodation  ;  it  does  not  dilate 
by  sensory  irritation  or  during  emotional  states,  a  medium  degree 
only  of  dilatation  is  produced  by  mydriatics,  but  maximum  con- 
traction is  produced  by  myotics.  The  pupil  is  more  contracted 
as  a  rule  in  spasmodic  than  in  paralytic  myosis. 

(c)  Combined  spastic  and  paralytic  myosis  causes  a  maximum 
degree  of  contraction  of  the  pupil,  which  is  also  completely  im- 
movable to  the  stimuli  of  light  and  accommodation,  as  well  as 
to  those  which  act  on  the  dilator  centres  and  fibres.  Mydriatics 
by  paralysing  the  sphincter  cause  a  medium  degree  of  dilata- 
tion, but  myotics  have  no  effect  upon  the  size  of  the  pupil. 

Diseases  in  which  Myosis  occurs. — Spastic  myosis  occurs  in 
all  diseases  which,  either  directly  or  indirectly,  irritate  the  third 
nerve.  The  irritation  is  sometimes  direct,  such  as  is  caused  during 
the  early  stages  of  the  growth  of  tumours  at  the  base  of  the 
brain,  basal  meningitis,  and  neuritis  of  the  third  nerve.  In  those 
•cases  the  myosis  is  associated  with  spasm  of  the  ciliary  muscle, 
and  of  the  internal  rectus.  At  other  times  the  irritation  is  reflex. 
It  may  be  laid  down  as  a  general  rule  that  all  painful  conditions 
of  the  eyeball,  such  as  ciliary  neuralgia  and  acute  inflammations 
of  the  conjunctiva,  cornea,  sclerotic,  and  iris,  are  associated  with 
a  considerable  degree  of  spastic  myosis.  At  other  times  the 
afferent  irritation  is  conducted  through  the  optic  nerves.  Mooren^ 
and  others  observed  a  moderate  degree  of  spastic  myosis  in 
retinitis  pigmentosa,  hypersesthesia  of  the  retina  being  present 
in  this  affection.  In  other  cases  the  cause  of  the  irritation  of  the 
third  nerve  is  situated  in  the  hemisphere  above  the  nucleus  of 
origin  of  the  third  nerve  in  the  crus.    Spastic  myosis  is  a  constant 

*  See  Leeser.     Op.  cit,  p.  89. 


DISEASES   OF  THE   MOTOR  CRANIAL   ISIERVES.  455 

symptom  of  the  early  stage  of  meningitis  of  the  convexity  of  the 
brain,  and  the  occurrence  of  dilatation  of  the  pupil  in  meningitis 
is  an  unfavourable  symptom  as  indicating  the  appearance  of  the 
second  or  paralytic  stage  of  the  affection.  Spastic  myosis  has 
been  observed  by  Griesinger  in  meningeal  apoplexy  and  hsemo- 
toma  of  the  dura  mater.  The  condition  is  also  often  present  in 
the  early  stages  of  the  growth  of  cerebral  tumours,  and  Berthold^ 
thinks  that  the  presence  of  contraction  followed  by  dilatation  of 
the  pupil,  which  he  observed  in  a  case  of  cerebral  haemorrhage, 
may  be  a  valuable  diagnostic  sign  between  haemorrhage  and 
embolus,  in  the  latter  of  which  changes  of  the  pupil  do  not  occur. 
Spasmodic  myosis  is  also  said  to  be  present  during  the  onset  of 
epileptic  and  hysterical  seizures.  It  is  sometimes  caused  by 
overstraining  of  the  eyes  in  cases  of  hypermetropia  or  by  looking 
at  small  objects,  and  in  these  cases  the  myosis  is  associated  with 
spasm  of  the  ciliary  muscle. 

Paralytic  myosis  is  caused  by  paralysis  of  the  dilator  centre  in 
the  pons  or  of  the  fibres  which  connect  it  with  the  pupil  in  any 
part  of  their  course.  It  is  found  in  affections  of  the  cilio-spinal 
region  of  the  spinal  cord,  rupture  of  the  roots  of  the  brachial 
plexus,  and  compression  of  the  cervical  sympathetic  by  tumours 
of  various  kinds.  As  a  functional  and  transient  symptom,  it  is 
present  in  the  neuroparalytic  form  of  hemicrania,^  Paralytic 
myosis  is  also  a  symptom  of  paralysis  of  the  trigeminus, 
caused  by  compression  of  it  at  the  base  of  the  skull ;  it  is  than 
caused  by  destruction  of  the  sympathetic  fibres  which  find  their 
way  to  the  lenticular  ganglion  along  with  the  fifth  nerve.  This 
form  of  myosis  is  a  very  frequent  symptom  of  locomotor  ataxy ; 
this  disease  is  caused  by  grey  degeneration  of  the  posterior 
columns  of  the  cord,  and  it  is  evident  that  the  dilator  fibres  in 
their  downward  progress  through  the  cilio-spinal  region  of  the 
cord  must  be  involved  in  the  lesion.  Paralytic  contraction  of 
the  pupil  is  also  found  in  progressive  paralysis  of  the  insane ;  it 
may  then  be  caused  by  changes  in  the  spinal  cord  analagous  to 
those  found  in  locomotor  ataxy,  or  by  cortical  disease  of  the 
frontal  lobes.     It  is  also  observed  in  acute  mania,  and  then  it  is 

'  Berthold,  "Fall  von  Hsemorrhagia  retinse  als  Verbote  einer  todtlich  verlau- 
fenden  Apoplexie."    Berl,  klin.  Wochenschr.,  1869,  p.  415. 

^  Du  Bois-Reymond.     Arch,  fiir  Anat,  und  Physiologie,  1860,  p.  461. 


456  DISEASES   OF  THE  MOTOE   CRANIAL   NERVES. 

caused  by  paralysis  of  the  cortical  dilator  centre.  This  form  of 
pupil  has  been  observed  during  the  pauses  of  breathing  in  the 
Cheyne-Stokes  respiration,  and  in  the  algide  stage  of  cholera/ 
caused  most  probably  by  paralysis  of  the  spinal  dilator  centre. 
It  is  met  with  in  alcoholic  amblyopia.^ 

Combined  spastic  and  paralytic  myosis  is  rare,  but  is  more 
commonly  met  with  as  a  complication  of  paralytic  than 
of  spastic  myosis.  A  person  may  have  had  a  long-standing 
paralytic  myosis,  and  to  this  a  spasm  of  the  sphincter  may  be 
superadded  during  strong  convergence  and  efforts  at  accommo- 
dation, or  the  spasm  may  result  from  ciliary  neuralgia,  or 
meningitis  of  the  convexity  of  the  brain.  In  long-standing 
paralysis  of  the  dilator  fibres  the  fibres  of  the  sphincter  undergo 
secondary  contraction,  so  that  a  high  degree  of  contraction  and 
comparative  immobility  of  the  pupil  is  attained,  or  a  condition 
closely  approaching  maximum  myosis. 

(2)  Mydriasis. — Three  forms  of  mydriasis  may  also  be  recog- 
nised, namely,  (<x)  spasmodic  or  spastic  mydriasis,  (6)  paralytic 
nnydriasis,  and  (c)  combined  spasmodic  and  paralytic  my- 
driasis. In  the  spastic  and  paralytic  forms  the  pupil  is  in  a 
medium  degree  of  dilatation  and  mobile  to  certain  stimuli,  and 
consequently  the  pupil  may  be  called  medium  or  labile  my- 
driasis;  while  in  the  combined  form  it  is  in  a  condition  of 
maximum  dilatation  and  immobile  to  all  stimuli,  and  conse- 
quently it  may  be  called  maximum  or  stabile  mydriasis. 

(a)  Spasmodic  Mydriasis. — In  this  variety  of  mydriasis  the 
pupil  is  in  a  state  of  medium  degree  of  dilatation ;  it  contracts 
slightly  to  light  and  during  efforts  at  accommodation,  but  does 
not  dilate  on  irritation  of  the  dilator  spinal  centre  either  through 
sensory  nerves  or  psychical  impressions.  It  is  difficult  to  contract 
by  myotics,  but  a  maximum  dilatation  is  readily  produced  by 
mydriatics. 

(b)  Paralytic  Mydriasis. — Paralytic  mydriasis  is  caused  by 
disease  of  the  spinal  contractor  centre,  or  of  the  aflferent  fibres 
which  connect  it  with  the  pupil,  by  arrest  of  the  afferent  fibres 
of  the  reflex  arc  in  the  optic  nerves,  or  by  destruction  of  the 
cortical  contractor  centre,  or  of  the  fibres  which  connect  it  with 

1  Graefe  (Von).    Arch.  f.  Ophth.    Bd.  XII.,  Abth.  2,  p.  198. 
"  Hirschler.    Arch.  f.  Ophth.    Bd.  XVII.,  Abth.  1,  p.  229. 


DISEASES   OF  THE  MOTOR   CRANIAL   NERVES.  457 

the  spinal  centre.  In  the  paralytic  form,  also,  the  pupil  is  in 
a  medium  degree  of  dilatation ;  it  dilates  further  on  sensory  or 
psychical  irritation  of  the  dilator  spinal  centre,  but  if  the 
efferent  fibres  between  the  contractor  spinal  centre  and  the 
iris  be  interrupted,  as  they  frequently  are,  the  pupil  fails  to  con- 
tract to  the  stimulus  of  light  or  to  accommodation.  If  the 
afferent  fibres  of  the  reflex  arc  in  the  optic  nerve  are  alone 
paralysed,  then  the  pupil  will  still  contract  during  efforts  at 
accommodation,  and  when  the  affection  is  unilateral  both  pupils 
will  contract  on  light  being  admitted  to  the  retina  of  the 
healthy  eye.  A  maximum  dilatation  is  readily  produced  by 
mydriatics,  but  a  medium  contraction  only  is  produced  by 
myotics. 

(c)  Combined  Spasmodic  and  Paralytic  Mydriasis. — In  this 
form  of  mydriasis  the  pupil  is  in  a  maximum  degree  of  dilata- 
tion and  completely  reactionless  to  all  kinds  of  stimuli.  It  is 
not  possible  to  obtain  further  dilatation  of  the  pupil  by  the  use 
of  mydriatics,  but  a  medinm  degree  of  contraction  is  produced 
by  myotics. 

Diseases  in  which  Mydriasis  occurs. — Spasmodic  mydriasis  is 
caused  by  direct  or  indirect  irritation  of  the  dilator  spinal  centre 
and  the  efferent  fibres  which  connect  it  with  the  iris.  Tabes 
dorsalis,  myelitis,  and  meningitis  of  the  cervical  region  of  the 
spinal  cord,  small  tumours  in  the  neighbourhood  of  the  cervical 
sympathetic,  and,  in  short,  almost  all  diseases  which  in  their  later 
stages  are  accompanied  by  paralytic  myosis,  may  in  their  early 
stage  be  associated  with  spasmodic  mydriasis.  In  a  case  of 
pachymeningitis,  under  my  care  at  present,  in  which  the  disease 
is  situated  opposite  the  eighth  cervical  and  first  dorsal  nerves, 
both  pupils  are  widely  dilated.  Spasmodic  mydriasis  is  usually 
present  during  severe  attacks  of  neuralgia  affecting  any  of 
the  nerves  of  the  body  except  the  first  division  of  the  fifth 
nerve.  It  is  also  observed  during  the  passage  of  renal  and 
biliary  calculi,  and  during  severe  attacks  of  gastralgia  and  colic ; 
and  may  sometimes  be  caused  by  the  presence  of  worms  in  the 
intestines,  and  is  a  valuable  sign  of  irritation  of  the  genital 
organs,  caused  by  sexual  excess  in  young  people.  Spasmodic 
dilatation  of  the  pupil  is  a  constant  symptom  of  spinal  irritation, 
and  is  present  in  ansemia  of  the  brain  with  or  without  general 


458  DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 

anaemia,  and  in  chlorosis,  but  in  the  latter  disease  it  is  probable 
that  the  empty  condition  of  the  blood-vessels  may  cause  some 
degree  of  dilatation  of  the  pupils  independently  of  any  disorder 
of  its  nervous  mechanism.  This  form  is  also  met  with  in 
psychical  disorders,  such  as  acute  mania,  melancholia,  and 
general  paralysis  of  the  insane,  being  often  unilateral  in  the 
last  disease.  According  to  Arndt^  unilateral  mydriasis,  with 
sluggishness  of  the  pupil,  is  a  sign  of  commencing  paralysis  of 
the  brain,  and  a  quickly  alternating  condition  of  mydriasis  and 
myosis  is  often  a  precursor  of  some  of  the  graver  psychoses.^ 
Spasmodic  mydriasis  is  also  present  in  those  diseases  in  which 
the  intracranial  pressure  is  increased,  as  in  many  cases  of  cerebral 
tumour  and  chronic  hydrocephalus.  It  is  also  met  with  in 
asphyxia,  the  pauses  of  breathing  of  the  Cheyne-Stokes  respira- 
tion, hooping  cough,  vomiting,  and  eclamptic  and  epileptic 
attacks. 

Dilatation  of  the  pupil  is  a  symptom  of  hemicrania  sympathico- 
tonica,  caused  doubtless  by  temporary  irritation  of  the  dilator 
centre  or  of  the  fibres  issuing  from  it.  It  is  met  with  in  many 
cases  of  cerebral  hsemorrhage  and  tumours,  the  second  stage  of 
meningitis,  thrombosis  of  the  sinuses,  in  neuritis  of  the  third 
nerve,  and  basal  tumours.  Paralytic  dilatation  of  the  pupil  is 
present  in  glaucoma,  it  is  then  caused  by  compression  of  the 
ciliary  nerves  within  the  eyeball  from  the  increased  intraocular 
pressure.  In  glaucoma  the  ciliary  nerves  are  not  always  equally 
affected,  and  consequently  the  pupil  is  often  irregular  from  the 
fibres  of  the  sphincter  being  paralysed  in  an  unequal  degree. 
Intraocular  tumours  of  all  kinds  have  the  same  effect  as  glau- 
coma upon  the  pupil.  The  dilatation  of  the  pupil  caused  by 
disease  of  the  afferent  fibres  of  the  reflex  arc  in  the  optic  nerve 
will  be  immediately  described. 

Combined  spasmodic  and  paralytic  mydriasis  is  rare ;  it  may 
be  met  with  when  irritation  of  the  dilator  mechanism  is  super- 
added to  a  previously  existing  paralytic  mydriasis,  and  conversely 
when  a  destructive  lesion  of  some  part  of  the  nervous  mechanism 
for  contraction  is  superadded  to  a  previously  existing  spasmodic 

1  Amdt  (R.).  "DieElectricitatin  derPsychiatrie."  Arch.  f.  Psychiat.,  Bd.  II., 
p.  589. 

^  Graefe  (V.).    Arch,  f,  Ophth.    Bd.  III.,  Abth.  2,  p.  359. 


DISEASES   OF  THE  MOTOR   CRANIAL   NERVES.  459 

mydriasis,  the  latter  variety  being  occasionally  met  with  in 
general  paralysis  of  the  insane,  A  condition  almost  similar  to 
maximum  mydriasis  is  induced  in  long-standing  cases  of  paralytic 
mydriasis,  when  the  dilator  fibres  undergo  paralytic  contraction, 
while  the  fibres  of  the  sphincter  become  permanently  paralysed 
and  atrophied. 

(3)  Complete  hnmohility  of  the  Pupil  tuith  Normal  Size. — 
This  condition  is  caused  by  paralysis  of  both  the  sphincter  and 
the  dilator  of  the  iris.  There  are  two  forms  of  this  condition, 
(a)  one  in  which  the  muscles  of  the  iris  are  alone  affected,  named 
iridoplegia,  and  (b)  one  in  which  all  the  internal  muscles  of  the 
eye  are  simultaneously  paralysed,  and  therefore  named  ophthal- 
moplegia interna. 

(a)  Iridoplegia. — In  iridoplegia  the  conditions  which  produce 
paralytic  myosis  and  paralytic  mydriasis  are  simultaneously 
present,  and  the  pupil  fails  to  respond  to  the  stimulus  of  light, 
and  does  not  contract  during  efforts  at  accommodation.  Hutchin- 
son states  that  the  power  of  being  acted  upon  by  myotics  and 
mydriatics  is  only  completely  lost  when  the  substance  of  the  iris 
itself  is  disorganised ;  but  cases  which  respond  to  the  action  of 
drugs  can  only  be  regarded  as  manifesting  partial  paralysis  of  the 
muscles. 

(h)  Ophthalmoplegia  Interna. — In  this  condition  all  the  in- 
ternal muscles  of  the  eye  are  paralysed;  the  pupil  is  completely 
reactionless ;  and  the  power  of  accommodation  to  near  vision  is 
lost.  Mr.  Hutchinson^  believes  that  isolated  paralysis  of  all  the 
internal  muscles  of  the  eye  is  caused  by  disease  of  the  lenticular 
ganglion.  Of  eight  cases  communicated  by  him,  both  eyes  were 
affected  in  five;  there  was  no  history  of  syphilis  in  three  of 
these  cases,  while  the  remaining  cases  were  of  syphilitic  origin. 

(4)  Clonic  Spasm  of  the  Muscles  of  the  Iris. — The  clonic  form 
of  spasm  of  the  muscles  of  the  iris  is  named  hippus,  or  chorea  of 
the  iris  ;  it  consists  of  quickly  alternating  contractions  and  dila- 
tations of  the  pupil,  and  depends  probably  upon  a  clonic  spasm  of 
the  sphincter.  It  sometimes  accompanies  nystagmus,  while  at 
other  times  it  is  observed  during  the  regressive  period  of 
paralysis  of  the  third  nerve. 

1  Hutchinson  (J.).  On  paralysis  of  the  internal  muscles  of  the  eye  (ophthal- 
moplegia interna).    Medico-Chirl  Transactions,  Vol.  LXI.,  1878,  p.  215. 


460  DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 

(5)  Disorders  of  the  Reflex  Movements  of  the  Iris. — The 
movements  of  the  iris  are  governed  by  two  reflex  ares,  the  one 
{a)  may  be  named  the  irido -dilator  s^ndi  the  other  Q>)  the  irido^ 
contractor  reflex  arc. 

{a)  Disorder  of  the  Irido-dilator  Reflex  Arc. — The  dilator 
reflex  arc  is  constituted  by  the  spinal  dilator  centre  in  the 
medulla  obloagata  and  the  efferent  fibres  which  connect  it 
with  the  iris  on  the  one  hand  and  the  afferent  fibres  which 
connect  it  with  the  periphery  of  the  body  generally  on  the 
other. 

The  disorders  of  the  dilator  arc  may,  therefore,  be  divided  into 
those  which  are  caused  by  (i.)  lesion  of  the  efferent,  and  (ii.)  of 
the  afferent  portion  of  the  reflex  arc. 

(i.)  Disorder  of  the  Efferent  Portion  of  the  Irido-dilator  Arc. 
In  a  case  of  locomotor  ataxia  under  examination  a  few  days  ago 
I  mentioned  before  some  students  the  presence  of  paralytic 
myosis  as  one  of  the  symptoms.  One  of  them  very  properly 
pointed  out  that  the  pupils  appeared  only  to  be  of  normal  size. 
I  then  showed  that  pinching  of  the  skin  of  the  neck  was  followed 
by  dilatation  of  the  pupil  in  a  healthy  subject,  while  no  move- 
ment was  caused  by  the  strongest  pinching  in  the  ataxic  patient, 
and,  as  there  was  no  sensory  disorder  of  the  skin  irritated,  the 
arrest  of  the  reflex  must  have  been  caused  by  lesion  of  the 
dilator  centre  or  of  the  efferent  fibres.  There  was  no  tumour  of 
the  neck  or  any  symptom  pointing  to  disease  of  these  fibres  in 
their  course  through  the  neck,  and  conseqiiently  the  efferent 
fibres  were  most  likely  to  be  affected  in  their  descending  course 
through  the  cervical  portion  of  the  spinal  cord  (Fig.  45,*).  The 
frequent  absence  of  this  reaction  in  locomotor  ataxia  was,  I 
believe,  first  pointed  out  by  Erb.^ 

(ii.)  Disorder  of  the  Afferent  Portion  of  the  Irido-dilator 
Arc. — It  was  proposed  by  Dr.  Lawson^  to  use  the  reflex  dilatation 
of  the  pupil  caused  by  strong  cutaneous  irritation  as  a  means  of 
determining  the  condition  of  the  sensory  conducting  paths  of  the 
spinal  cord  in  cases  of  partial  anaesthesia,  and  more  especially  as 

'  Erb  (W.).  "  Spinal  myosis  and  reflex  pupillary  immobility."  Reprinted  from 
the  Archives  of  Medicine.     New  York,  Oct.,  1880. 

^  Lawson  (R.)  and  Lewis  (Bevan).  "  Clinical  notes  on  conditions  incidental  to 
insanity."    "West  Riding  Asylum  Reports,  Vol.  VI.,  1876,  p.  139. 


DISEASES   OF  THE  MOTOR  CRANIAL   NERVES.  461 

a  means  of  detecting  imposture.  In  using  this  test  the  skin  of 
the  foot  is  pricked,  strongly  pinched,  or  otherwise  irritated ;  if 
the  sensory  conducting  paths  are  normal,  and  no  disease  exists 
in  the  dilator  centre  or  in  the  fibres  which  connect  it  with  the 
iris,  the  pupil  immediately  dilates.  In  true  spinal  anaesthesia 
this  reaction  is  arrested ;  but  in  simulated  anaesthesia,  cerebral 
anaesthesia,  and  probably  also  in  hysterical  anaesthesia,  the  reflex 
action  is  not  interfered  with. 

(6)  Disorder  of  tJie  Irido-contractor  Reflex  Arc. — The  con- 
tractor reflex  arc  is  constituted  by  efferent  fibres  which  issue  from 
the  nucleus  of  the  third  nerve  in  the  crus  cerebri  and  are  con- 
ducted by  the  third  nerve,  short  root  of  the  lenticular  ganglion, 
and  ciliary  nerves  to  the  iris,  and  by  afferent  fibres  which  run  in 
the  optic  nerves  and  tracts  to  the  corpora  quadrigemina.  The 
central  ends  of  the  efferent  and  afferent  fibres  are  connected  by  a 
loop  of  fibres  disease  of  which  causes  a  reflex  immobility  of  the 
pupil,  a  disorder  that,  from  the  author  who  first  described  it,  is 
often  named  the  Argyll-Rohertson  pupiL  The  disorders  of  the 
contractor  reflex  arc  may  therefore  be  divided  into  those  which 
are  caused  by  lesion  (i.)  of  the  efferent,  (ii.)  of  the  afferent  fibres 
of  the  arc,  and  (iii.)  of  the  loop  which  connects  the  two,  the 
latter  giving  rise  to  the  Argyll-Robertson  pupil. 

(i.)  Disorder  of  the  Efferent  Portion  of  the  Irido-contractor 
Reflex  Arc. — This  affection  is  caused  by  lesion  of  the  contractor 
centre  in  the  crus  cerebri,  or  of  the  fibres  connecting  it  with  the 
iris;  it  is  associated  with  paralytic  mydriasis,  cycloplegia,  and 
generally  with  other  symptoms  indicative  of  disease  of  the  third 
nerve.     It  need  not  detain  us  further. 

(ii.)  Disorder  of  the  Afferent  Portion  of  the  Irido-contractor 
Reflex  Arc. — The  afferent  portion  of  the  contractor  reflex  arc  runs 
in  the  optic  nerves  and  tracts  to  reach  the  corpora  quadrigemina. 
In  blindness  and  atrophy  of  the  optic  nerves  the  afferent  part  of 
the  reflex  is  implicated  in  the  disease,  the  sphincter  of  the  iris 
loses  its  tone,  and  the  pupil  dilates  provided  the  sympathetic 
mechanism  be  free  from  disease,  which  is  not  always  the  case. 
The  pupils  also  fail  to  contract  to  light,  but  still  contract  when  the 
eyes  are  converged.  In  unilateral  blindness  with  atrophy  both 
pupils  fail  to  contract  when  light  is  admitted  on  the  affected 
side,  but  both  contract  readily  when  light  is  admitted  to  the 


462  DISEASES   OF  THE  MOTOR   CRANIAL   NERVES. 

sensitive  eye,  because  the  central  end  of  the  contractor  reflex  arc 
is  connected  with  its  fellow  of  the  opposite  side  by  commissural 
fibres.  In  blindness  from  lesion  situated  above  the  corpora 
quadrigemina  contraction  of  the  pupil  to  light  is  retained,  because 
the  reflex  arc  is  unaffected,  and  consequently  the  presence  or 
absence  of  reflex  contraction  to  light  in  cases  of  blindness  is  a 
valuable  diagnostic  sign  in  determining  the  localisation  of  the 
lesion.  In  cases  of  hemianopsia,  likewise  caused  by  compression 
of  one  of  the  optic  tracts  it  is  probable  that  reflex  contraction  is 
more  interfered  with  on  the  side  of  the  lesion  than  on  the  oppo- 
site side,  while  there  is  no  interference  with  the  reflex  when  the 
lesion  is  situated  in  the  substance  or  cortex  of  the  occipital 
lobe.-^  The  whole  of  this  subject,  however,  has  not  yet  been 
thoroughly  worked  out,  and  there  is  great  need  for  fresh 
observations. 

(iii.)  The  Argyll- Robertson  Pupil. — In  this  condition  there  is 
absence  of  the  reflex  contraction  to  light,  while  the  associated 
contraction  of  the  pupil  with  accommodation  is  retained,  and 
vision  is  usually  normal.  The  absence  of  any  paralysis  of  the 
sphincter  or  of  blindness  shows  that  the  efferent  and  afferent 
fibres  of  the  reflex  arc  are  unaffected,  and  consequently  the 
lesion  must  be  situated  in  the  fibres  which  connect  the  corpora 
quadrigemina  with  the  nucleus  of  the  third  nerve  {Fig.  45,  a). 
This  symptom  is  most  frequently  observed  in  locomotor  ataxia, 
a  disease  which  results  from  sclerosis  of  the  posterior  columns  of 
the  spinal  cord,  and  their  upward  continuations  in  the  medulla 
oblongata,  pons,  and  crura  cerebri,  and  it  must  therefore  be 
assumed  that  the  loop  which  connects  the  efferent  and  afferent 
fibres  of  the  contractor  reflex  arc  passes  through  the  homologues 
of  the  posterior  columns  of  the  cord  in  the  crus  cerebri.  This 
condition  of  the  pupil  is  also  met  with  in  progressive  paralysis 
of  the  insane,  as  well  as  in  other  forms  of  the  graver  psychoses, 
and  I  have  at  present  under  observation  a  case  of  sclerosis  in 
patches,  in  which  the  phenomenon  is  well  marked. 

This  condition  was  first  described  by  Argyll-Robertson,^  and  it 

1  Dreschfeld  (J.).  "Pathological  contributions  on  the  course  of  the  optic  nerve 
fibres  in  the  brain."    Brain,  Vol.  IV.,  1881,  p.  542. 

'  Argyll-Robertson.    "  On  an  interesting  series  of  eye  symptoms  in  a  case  of 
spinal  disease,  &c."    Edinburgh  Medical  Journal,   Vol.  XIV.,   1868-69,  p.  697 
and  "  On  the  physiology  of  the  iris."    The  Lancet,  Vol.  I.,  1870,  p.  211. 


DISEASES   OF  THE   MOTOR   CRANIAL   NERVES.  463 

has  since  been  studied  by  Knapp,^  Wernicke/  Hempel,^  Vincent,* 
Erb,^  Grainger  Stewart,®  and  others. 

Treatment. — The  treatment  of  the  various  disorders  of  the 
pupil  depends  upon  the  disease  with  which  each  is  associated. 

(II.)— DISEASES  OF  THE  FACIAL  NERVE. 

The  facial  nerve  is  the  motor  nerve  of  the  face.  It  is  dis- 
tributed to  most  of  the  muscles  of  the  ear  and  to  the  muscles  of 
the  scalp,  to  those  of  the  mouth,  nose,  and  eyelids,  and  to  the 
cutaneous  muscles  of  the  neck.  The  reader  should  remember 
that  the  chorda  tympani,  with  its  gustatory  fibres  and  its  secre- 
tory and  vaso-motor  fibres  to  the  submaxillary  gland,  accom- 
panies the  facial  nerve  in  a  portion  of  the  Fallopian  canal ;  the 
annexed  diagrams  {Figs.  46  and  47)  will  suffice  to  remind  him 
of  the  course,  connections,  and  distribution  of  the  facial  nerve, 
and  of  the  muscles  to  which  it  is  supplied,  without  detailed 
description. 

§  241.  Spasm  in  the  Area  of  Distribution  of  the  Facial  Nerve. 
Histrionic  Spasm  of  the  Face.  Mimic  Convulsion. 
Convulsive  Tic. 

Spasmodic  action  of  the  facial  muscles  occurs  in  various 
diseases  of  the  nervous  system,  as  epilepsy  and  tetanus,  but 
the  disease  under  consideration  at  present  is  a  local  affection 
confined  to  the  muscles  supplied  by  one  of  the  seventh  pair  of 
nerves,  or  by  one  of  its  branches. 

The  disease  is  caused  either  by  direct  or  reflex  irritation  of  the 
facial  nerve.  The  direct  causes  are  the  same  generally  as  those 
which  cause  facial  paralysis,  such  as  exposure  to  cold,  tumour 

1  Knapp.     Arch,  of  ophth.  and  otology.    Vol.  II.,'  Part  2,  1872,  p.  167. 

*  Wernicke  (C).  Das  Verhalten  der  Pupillen  bei  Geisteskranken.  Virchow's 
Archives,  Bd.  LVI.,  1872,  p.  405. 

*  Hempel.  "  Ueber  die  Spinalmyosia."  Arch.  f.  Ophth.,  Bd.  XXII.,  Abth.  1, 
1876,  p.  1. 

*  Vincent.  Des  phenomenes  oculo-pupillairea  dans  I'ataxie  locomotrice  progres- 
sive et  la  paralysie  g^n€rale  des  alienes.     These  de  Paris,  1877. 

*ErbCW.).  "Zur  Pathologic  der  Tabes  dorsalis."  Deutsches  Arch.  f.  klin. 
Med.,  Bd.  XXIV.,  1879,  p.  1 ;  and  Archives  of  Medicine,  New  York,  1880. 

°  Stewart  (Grainger).  "The  eye  symptoms  in  locomotor  ataxia."  Brain, 
Vol.  II.,  1880,  p.  185. 


464 


DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 


at  the  base  of  the  brain/  aneurism  of  the  vertebral  artery,^ 
inflamed  gland  in  the  vicinity  of  the  stylo-mastoid  foramen,^ 


Fig.  46  (from  Hermann's  "  Physiology").    Diagram  of  the  Facial  Nerve,  its  con- 
nections and  branches. 

F,  The  facial  nerve.  A,  Auditory  nerve. 

1,  The  geniculate  ganglion. 

gsp,  Great  superficial  petrosal  nerve  connecting  the  facial  and  Meckel's 

ganglion. 
ssp,  Small  superficial  petrosal  nerve  connecting  the  facial  with  the  Otic 

ganglion  and  with  the  tympanic  branch  of  the  glosso-pharyngeal. 
esp,  External  superficial  petrosal  connecting  the  facial  with  the  plexus 

on  the  middle  meningeal  artery. 

2,  Chorda  tympani,  joining  lingual  nerve. 

3,  Nerve  to  stapedius  muscle. 

4,  Communicating  branch  with  the  ganglion  of  the  root  of  the  vagus. 

5,  Posterior  auricular  nerve. 

6,  Branch  to  the  stylo-hyoid  and  digastric  muscles. 

II  terfaSSlr  ]  to  --^-  «^  -p---- 

V,  Fifth  nerve.        at,  Auriculo-temporal  branch. 

id.  Inferior  dental  nerve.  I,  Lingual  nerve. 

MGr,  Meckel's  ganglion. 
0G-,  Otic  ganglion. 
SG-,  Submaxillary  ganglion. 
IM,  Internal  maxillary  artery. 
MM,  Middle  meningeal  artery. 
P,  Pneumogastric  nerve. 
GP,  Glosso-pharyngeal  nerve. 

(,  Its  tympanic  branch  (nerve  of  Jacobson), 

'  Schuh.  Quoted  in  Rosenthal's  Treatise  of  the  diseases  of  the  nervous  system. 
New  York,  1867.    p.  467. 

*Schultze  (F.).  " Linksseitiger  Facialiskrampf^  in  Folge  sines  Aneurysma  der 
art.  vertebralis  sinistra."    Virchow's  Arch.,  Bd.  LXV.,  p.  385. 

^Romberg.  A  manual  of  the  nervous  diseases  of  man.  Vol.  I.,  Lond.,  1S53, 
p.  293. 


DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 


465 


abscess  of  the  parotid  gland,^  caries  of  the  petrous  portion  of 
the  temporal  bone,^  and  otitis.^  Spasm  in  the  region  of  some  of 
the  branches  of  the  facial  nerve  may  also  be  caused  by  tumour* 
or  abscess  in  the  lower  end  of  the  pons  at  a  stage  when  the 
compression  of  the  fibres  is  not  sufficient  to  cause  paralysis. 
The  reflex  irritation  is  generally  conveyed  by  the  trigeminus;  the 
most  usual  sources  of  irritation  are  trigeminal  neuralgia,  carious 
teeth,  irritation  of  the  eyeball  and  of  the  conjunctiva.  The 
source  of  the  irritation  is  sometimes  remote.     Remak^  relates  a 

Fig.  47. 


Fig.  47  (from  Heath's  "Anatomy").  Muscles  of  the  Head  and  Face. — 1,  Frontal 
portion  of  the  occipito-frontalis.  2,  Its  occipital  portion.  3,  Its  aponeurosis. 
4,  Orbicularis  palpebrarum,  which  conceals  the  corrugator  supercilii  and  tensor 
tarsi.  5,  Pyramidalis  nasi.  6,  Compressor  naris.  7,  Orbicularis  oris.  8, 
Levator  labii  superioris  alseque  nasi ;  the  adjoining  fasciculus  between  num- 
bers 8  and  9  is  the  labial  portion  of  the  muscle.  9,  Levator  labii  superioris 
proprius  ;  the  lower  part  of  the  levator  anguli  oris  is  seen  between  the  muscles 
10  and  11.  10,  Zygomaticus  minor.  11,  Zygomatious  major.  12,  Depressor 
labii  inferioris.  13,  Depressor  anguli  oris.  14,  Levator  labii  inferioris.  15, 
Superficial  portion  of  the  masseter.  16,  Part  of  its  deep  portion.  17,  Attrahens 
aurem.  18,  Buccinator.  19,  AttoUens  aurem.  20,  Temporal  fascia  covering 
the  temporal  muscle.  21,  Eetrahens  aurem.  22,  Anterior  belly  of  the  digas- 
tricus.  23,  Stylo-hyoid  pierced  by  posterior  belly  of  the  digastric.  24,  Mylo- 
hyoideus.     25,  Sterno-mastoid,     26,  Trapezius. 

'■  Debrou.  "  Sur  le  tic  non-douloureux  de  la  face."  Arch.  g^n.  de  med.,  6^  Serie, 
Tome  III.,  1864,  p.  641. 

*  Oppolzer.    Allg.  Wiener  med.  Zeitung.     1861.     Nov.  10. 

^  Rosenthal  (M.).  A  clinical  treatise  on  the  diseases  of  the  nervous  system. 
New  York,  1879.    p.  467. 

■*  Hobson  (S.  M.).    Brain.    Vol.  IV.,  1882,  p.  531. 

*Remak.  "  Ueber  Gesichtskrandpf."  BerL  klin.  Wochenschr,,  Bd.  I.,  1864, 
p.  222. 

VOL.  L  E  E 


466  DISEASES  OF   THE  MOTOR  CRANIAL  NERVES. 

case  of  spasmodic  actions  of  the  muscles  of  the  hand  and  arm 
extending  to  the  muscles  of  the  neck  and  face  of  the  same 
side,  which  was  caused  by  cervico-brachial  neuritis,  and  in  which 
knotty  points  could  be  felt  along  the  course  of  the  affected  nerves. 
The  disease  may  also  be  caused,  especially  in  children,  by  intes- 
tinal irritation  from  the  presence  of  worms,  and  in  females  by 
uterine  irritation.^ 

Occasionally  it  appears  to  be  inherited.  RosenthaP  men- 
tions the  case  of  a  family  where  a  mother,  her  son,  sister,  and 
two  other  relations,  were  affected  with  a  more  or  less  degree 
of  facial  spasm.  The  affection  often  results  from  emotional 
disturbances.  In  the  case  of  a  lady  known  to  me  the  spasm 
began  in  consequence  of  a  long  and  anxious  nursing  of  a  sick 
relative,  but  it  is  possible  that  general  exhaustion  and  exposure 
to  a  draught  of  cold  air  had  concurred  to  cause  the  disease  in 
this  case.  Romberg^  mentions  an  instance  in  which  the  disease 
affected  a  female  in  consequence  of  the  shock  caused  by  the 
sudden  death  of  her  husband.  Sometimes  the  affection  begins 
in  one  of  the  muscles  supplied  by  the  facial  nerve,  such  as  the 
lower  eyelid,  and  gradually  extends  to  the  other  muscles  in  the 
absence  of  any  recognisable  cause.^ 

§  242.  Symptoms. — Histrionic  spasm  of  the  face  may  be  clonic 
or  tonic,  the  former  variety  being  by  far  the  more  frequent  of 
the  two. 

The  clonic  form  of  the  affection  is  composed  of  periodically 
recurring  attacks  of  spasm,  each  paroxysm  consisting  of  sudden 
and  violent  contractions  and  relaxations  of  some  of  the  muscles 
of  the  face.  The  duration  of  each  paroxysm  varies  from  a  few 
seconds  to  a  few  minutes,  and  ceases  only  to  be  succeeded 
after  a  short  interval  by  another ;  the  spasm  may  be  excited 
by  emotional  disturbances,  voluntary  movements  of  the 
affected  muscles,  or  reflex  irritation,  and  in  severe  cases 
they  arise  spontaneously  and  without  any  exciting  cause.     The 

1  Eulenburg  (A.).  Eeal-EncyclopadiedergesammtenHeilkunde.  Art.  "Gesichts- 
muskelkrampf."    Bd.  VI.,  1881,  p.  28. 

^  Rosenthal  (M.).     Op.  cit.,  p.  467. 

^  Romberg.    Op.  cit.,  p.  294. 

♦  See  Graves.    The  Dublin  Medical  Journal,  Vol.  XXII.,  1842,  p.  395. 


DISEASES   OF   THE  MOTOR  CRANIAL  NERVES.  467 

paroxysms,  as  a  rule,  disappear  during  sleep.  The  spasm  is 
generally  confined  to  the  one  side  of  the  face,  so  that  the 
contortions  and  grimaces  of  the  affected  side  contrast  strangely 
with  the  calm  and  natural  expression  of  the  opposite  side. 
The  contortions  produced  are  extremely  variable,  and  consist 
mainly  of  elevation  and  depression  of  the  occipital  and  frontal 
muscles,  corrugation  of  the  eyebrows,  twitching  or  winking  of 
the  eyelids,  elevation  of  the  cheek  and  of  the  nostrils,  and  dis- 
tortion of  the  angle  of  the  mouth ;  these  may  be  present  in 
every  imaginable  combination.  The  spasm  may  be  partial, 
being  limited  to  the  muscles  supplied  by  single  branches  of  the 
nerve.  The  palpebral  twigs  alone  are  sometimes  affected,  and 
the  affection  then  manifests  itself  by  a  rapid  winking,  called 
nictitating  spasm;  or  there  may  be  only  slight  twitching 
movements  of  one  of  the  eyelids,  the  lower  being  the  one  most 
usually  affected.  When  the  malar  and  labial  branches  are  impli- 
cated it  gives  rise  to  a  convulsive  grin,  on  one  or  on  both  sides, 
resembling  laughing,  and  consequently  called  the  sardonic 
laugh,  risus  caninus,  or  cynic  spasm. 

The  whole  of  the  facial  nerve  may  at  times  be  implicated,  so 
that  not  only  the  facial  muscles  but  the  platysma  myoides  is 
affected.  Facial  tic  also  occurs  in  connection  with  spasm  of  the 
muscles  supplied  by  other  nerves,  as  the  fifth,  hypoglossal,  spinal 
accessory,  or  some  of  the  spinal  nerves.  Speaking  of  the  asso- 
ciation of  spasm  of  the  muscles  of  the  face  and  neck,  Sir  C.  Bell^ 
remarks :  "  Then  we  see  the  head  suddenly  twitched  sidewise 
at  the  same  moment  that  the  mouth  is  drawn  aside.  This  is 
a  great  deformity;  for  while  the  individual  is  animated  and 
speaking  with  exertion,  he  gives  those  sudden  startling  motions, 
opening  his  mouth  and  turning  it  to  his  shoulder,  as  if  he  were 
catching  flies." 

The  muscles  supplied  by  the  auricular  muscular  branches  of 
the  facial  are  rarely  affected.  Romberg"^  mentions  two  cases 
in  which  these  muscles  were  the  subjects  of  spasm.  In  the 
first  case  the  spasmodic  movements  occurred  in  paroxysms,  and 
appeared  after  partial  recovery  from  apoplexy,  and  was  accom- 

'  Bell  (Sir  C).    The  nervous  system  of  the  human  body.    Lond.,  1830.    p.  160. 
'^  Romberg.     Op.  cU.,  p.  292. 


468  DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 

panied  by  paralysis  of  the  right  arm  ;  in  the  other  case  the  spasm 
preceded  an  epileptic  seizure,  and  thus,  as  Romberg  remarks, 
took  the  place  of  the  aura.  It  is  quite  evident,  therefore,  that 
neither  of  these  cases  is  a  true  instance  of  the  disease  under 
consideration  at  present. 

The  paroxysms  are  not  usually  accompanied  by  pain,  although 
occasionally  at  an  early  stage  some  numbness  or  even  a  slight 
degree  of  pain  may  be  present,  and  the  patient  may  also  complain 
of  headache  and  tinnitus  aurium;  but  sensory  disorders  never 
form  a  prominent  feature  of  the  disease.  All  the  voluntary 
movements  can  be  executed  with  undiminished  power,  there 
are  no  vaso-motor  or  secretory  disturbances,  and  the  electrical 
reactions  are  normal.  Certain  points  may  be  found,  pressure  on 
which  will  arrest  the  spasm;  these,  when  present,  correspond 
with  the  pressure  points  in  trigeminal  neuralgia. 

The  tonic  form  of  facial  spasm  was  first  clearly  recognised  by" 
Dr.  Marshall  Hall.^  In  this  form  the  muscular  contraction  is 
persistent.  The  tip  of  the  nose,  angle  of  the  mouth,  and  the 
chin  are  drawn  to  the  affected  side,  and  the  furrows  and  dimples 
of  that  side  are  rendered  deeper.  The  contracted  muscles  render 
the  tissues  on  the  affected  side  too  scanty  for  covering  the 
orifices,  so  that  when  the  eye  is  closed  a  tightness  is  induced  at 
the  angle  of  the  mouth,  and  when  the  angle  of  the  mouth  is 
removed  from  the  eye,  as  in  speaking,  it  is  difficult  to  keep  the 
latter  closed.  Articulation  is  rendered  indistinct,  and  the  bolus 
of  food  tends  to  collect  between  the  teeth  and  the  affected  cheek, 
causing  slight  trouble  during  mastication,  but  there  is  no  diffi- 
culty of  deglutition. 

Blepharospas7}i,  the  most  important  of  the  partial  forms  of 
facial  spasm,  has  been  carefully  studied  by  Von  Graefe.^  This 
affection  consists  of  a  paroxysmal  closure  of  the  eyelids,  which 
may  last  from  a  few  minutes  to  a  few  hours,  but  may  occasionally 
extend  over  a  period  of  weeks  or  of  months.  It  is  generally 
accompanied  by  photophobia,  and  is  sometimes  associated  with 
trigeminal  neuralgia;  the  disease  indeed  is  generally  of  reflex 


•  Hall  (Marshall).     On  the  diseases  and  derangements  of  the  nervous  system. 
Lond.,  1841.     p.  342. 

*  Von  Graefe  (A.).    Arch,  f .  Ophthal,  Bd.  I.,  Abth.  1,  p.  441 ;  Bd.  IV.,  Abth.  2, 
p.  184 ;  and  Bd.  IX.,  Abth.  2,  p.  73. 


DISEASES  OF  THE  MOTOR  CRANIAL   NERVES.  469 

origin,  and  caused  by  irritation  of  the  ocular  branches  of  the  fifth 
nerve.  Pressure  on  the  points  which  correspond  to  the  tender 
points  in  trigeminal  neuralgia,  and  especially  over  the  infra- 
orbital foramen,  may  completely  arrest  the  spasm. 

§  243.  Course,  Duration,  Terminations,  and  Prognosis. — 
The  course  of  the  facial  tic  is  generally  chronic,  and  it  may  last 
during  the  lifetime  of  the  patient.  Complete  recovery  is  pro- 
bably the  rarest  termination,  the  most  frequent  being  partial 
recovery  with  relapses.  The  prognosis  varies  with  the  cause. 
It  is  most  favourable  when  the  spasm  depends  upon  a  curable 
disease  of  the  eye  or  conjunctiva,  or  upon  some  other  source  of 
peripheral  irritation. 

§  244.  Diagnosis. — The  tonic  form  of  facial  spasm  may  be 
mistaken  for  facial  paralysis  of  the  opposite  side,  but  in  the 
former  affection  the  immobility  is  found  on  the  side  to  which  the 
face  is  drawn,  while  the  reverse  obtains  in  the  latter.  In  spasm, 
the  affefcted  muscles  are  prominent  and  rigid,  and  their  faradic 
contractility  is  normal  or  exaggerated,  while  in  paralysis,  the 
affected  muscles  are  flaccid,  and  their  faradic  contractility  is 
often  diminished  or  lost. 

§  245.  Morbid  Anatomy  and  Physiology. — The  disease  is  no 
doubt  caused  by  irritation,  either  direct  or  reflex,  of  the  seventh 
nerve,  or  of  one  of  its  branches.  The  irritation  may  be  the  result 
of  disease,  such  as  a  tumour,  abscess,  or  cicatrix,  in  the  vicinity 
of  the  nerve  at  any  part  of  its  course.  The  affection  is  at  other 
times  caused  in  a  reflex  manner  by  irritation  of  the  fifth  nerve 
or  by  a  remote  irritation.  Spasm  in  the  region  of  the  facial 
nerve  may  be  caused  by  irritation  of  the  fibres  of  the  pyramidal 
tract,  which  connect  the  nucleus  of  the  nerve  in  the  medulla 
and  pons  with  the  posterior  part  of  the  third  frontal  convolution 
of  the  opposite  hemisphere,  or  of  the  cortical  centre  itself. 
Spasm  of  the  facial  nerve  from  cerebral  disease  is  most  fre- 
quently caused  by  syphilitic  disease  of  the  cortex,  but  it  then 
only  forms  a  part  of  a  more  extensive  spasm  named  unilateral 
epilepsy.     These  cases  will  be  subsequently  described. 


470  DISEASES  OF  THE  MOTOR   CRANIAL  NERVES. 

§  246.  Treatment. — The  first  aim  of  treatment  must  be  to 
remove  the  cause  of  the  affection.  If  the  disease  is  the  result  of 
exposure  to  cold,  soothing  applications,  such  as  the  vapour  bath, 
ought  to  be  employed,  while  opium  may  be  given  in  some  form 
internally,  or  a  subcutaneous  injection  of  morphia  may  be 
administered.  When  the  spasm  results  from  irritation  of  the 
facial  nerve  by  a  tumour,  enlarged  glands,  or  cicatrix,  the  source 
of  the  irritation  must  be  removed  if  possible.  When  reflex 
irritation  exists,  the  treatment  must  be  directed  against  its 
source.  The  irritation  sometimes  originates  in  the  intestinal 
canal,  especially  that  caused  by  the  presence  of  worms,  or  from 
the  uterus,  and  consequently  the  functions  of  these  organs  must 
be  carefully  investigated  and  regulated. 

The  cause  of  the  irritation  may  be  conveyed  to  the  nerve 
through  the  blood,  hence  the  constitutional  state  of  the  patient 
must  be  investigated.  If  rheumatism  be  present,  salicylic  acid 
would  be  a  suitable  remedy,  and,  if  that  failed,  iodide  of 
potassium.  If  the  patient  be  scrofulous,  carbonate  of  iron  and 
cod-liver  oil  would  be  likely  to  prove  the  best  remedies.. 

If  the  affection  is  associated  with  chorea,  arsenic  and  bromide 
of  zinc  are  the  most  likely  remedies  to  succeed,  or  large  doses  of 
the  bromide  of  potassium  might  be  tried ;  I  have  much  more 
faith  in  arsenic  given  in  progressively  increasing  doses,  up  to 
from  seven  to  ten  minims  of  the  liquor,  than  in  any  other 
remedy. 

The  best  direct  treatment  consists  of  the  application  of  the 
constant  current.  When  points  of  arrest  are  obtained,  the 
anode  should  be  placed  over  one  of  these,  and  in  other  cases 
the  descending  current  may  be  passed  along  the  facial  nerve  to 
the  affected  muscles.  The  patient  should  be  directed  to  exert 
his  will  to  the  utmost  to  control  the  facial  movements,  just  as  he 
would  do  in  endeavouring  to  overcome  a  bad  habit.  The  appli- 
cation of  chloroform,  ether  spray,  and  subcutaneous  injections 
of  morphia  will  be  found  useful  alternately  as  local  applications. 
When  the  spasm  does  not  yield  to  medical  treatment,  recourse 
may  be  had  to  some  surgical  procedure.  Continued  pressure  by 
means  of  a  small  compress,  either  on  the  trunk  of  the  nerve,  at 
its  exit  from  the  stylo-mastoid  foramen,  or  on  one  of  its  divisions, 
according  to  the  extent  of  the  disease,  has  been  found  useful. 


DISEASES   OF  THE  MOTOR   CRANIAL  NERVES.  471 

When  a  point  can  be  discovered  over  one  of  the  branches  of  the 
fifth  nerve,  pressure  upon  which  arrests  the  spasm,  the  compress 
ought  to  be  applied  over  this  point.  Dieffenbach  divided  sub- 
cutaneously  all  the  muscles  affected  with  spasm,  and  the  convul- 
sions immediately  ceased.  A  year  and  a  half  after  the  operation, 
all  that  remained  was  some  degree  of  tremor  and  agitation. 
Section  of  the  facial  nerve  has  been  recommended,  but  the 
paralysis  which  results  is  a  fatal  objection  to  the  treatment. 
Nerve  stretching  is  much  less  objectionable,  and  several  cases 
are  now  recorded  in  which  the  operation  proved  successful.  In 
a  very  aggravated  case  of  facial  spasm  under  my  own  care  Mr. 
Southam^  stretched  the  nerve ;  the  operation  was  followed  by 
paralysis  of  the  muscles,  but  motor  power  gradually  returned, 
and  now  not  a  trace  of  paralysis  or  spasm  can  be  detected. 

§  247.  Paralysis  of  the  Seventh  Nerve.  Mimetic  Facial  Para- 
lysis. Hemiplegia  and  Diplegia  Facialis.  Prosopalgia. 
Bell's  Paralysis. 

Paralysis  of  the  facial  nerve  was  first  thoroughly  investigated 
by  Sir  Charles  Bell,^  and  consequently  it  is  now  frequently  called 
Bell's  Paralysis.  There  is  probably  no  nerve  in  the  body  so 
liable  to  be  independently  attacked  as  the  facial.  Its  superficial 
position  exposes  it  to  various  traumatic  influences,  while  its 
course  through  a  long  and  narrow  bony  canal,  and  its  proximity 
to  organs  very  liable  to  be  diseased,  afford  numerous  oppor- 
tunities for  the  occurrence  of  various  lesions  of  the  nerve,  and 
render  it  peculiarly  liable  to  become  secondarily  implicated. 

Paralysis  of  the  facial  is  sometimes  unilateral,  sometimes 
bilateral,  and  all  the  branches,  or  particular  branches  only,  may 
be  affected. 

§  248.  Etiology. — Exposure  of  one  side  of  the  face  to  cold  is 
one  of  the  most  frequent  causes  of  paralysis  of  the  seventh 
nerve,  and  it  is  then  called  rheumatic  paralysis.     The  paralysis 

1  Southam  (F.  A.),  The  Lancet,  Vol.  XL,  1881,  p.  370.  See  also  Sturge  and 
Godlee.  The  Lancet,  Vol.  II.,  1880,  p.  814.  Schussler  (H.).  "  Mimischer 
Gesichtskrampf :  Dehnung  des  Facialis,"  Berl.  klin.  Wochenschr.,  Bd.  XVI., 
1879,  p.  684.     And  Bernhardt.     Centralbl.  fiir  Nervenheilkunde,  1882,  p.  405. 

^  Bell  (C).  The  Nervous  System  of  the  Human  Body.  London,  1838.  p.  142  ; 
and  Appendix,  p.  iv.  et  seq. 


472  DISEASES  OF  THE  MOTOR   CRANIAL  NERVES. 

is  probably  due  to  a  slight  neuritis,  followed  by  serous  or  plastic 
exudation  into  the  sheath  of  the  nerve,  which  compresses  the 
nerve  fibres. 

Facial  paralysis  occurs  at  all  ages,  but  it  is  most  frequent 
between  twenty  and  forty  years  of  age.  Sex  does  not  seem  to 
exert  any  influence,  and  each  side  of  the  face  is  about  equally 
liable  to  be  affected.  It  is  frequently  the  result  of  injury,  and 
has  been  observed  after  a  severe  blow  on  the  ear,  gunshot  and 
various  other  wounds,  and  fractures  of  the  temporal  bone.  Para- 
lysis of  the  facial  and  auditory  nerves  is  regarded  by  Prescott 
Hewitt^  as  one  of  the  most  common  signs  of  fracture  of  the  base 
of  the  skull,  and  he  states  that  in  such  cases  one  of  the  nerves 
may  be  injured  and  not  the  other.  He  believes  that  the  injury 
sometimes  consists  of  extravasation  of  blood  within  the  sheath 
of  arachnoid  surrounding  these  nerves,  and  he  has  seen  "a  clot 
of  extravasated  blood  lying  between  the  nerves,  at  the  bottom  of 
the  meatus  internus."  It  also  occurs  after  extirpation  of  the 
parotid  gland  and  other  surgical  operations  about  the  face  and 
ear,  and  may  be  caused  in  new-born  infants  by  the  pressure 
of  the  forceps.^  Affections  of  the  parotid  and  of  the  neigh- 
bouring parts  may  cause  facial  paralysis  either  by  pressure  on 
the  trunk  of  the  nerve  or  of  one  of  its  branches,  or  by  exten- 
sion of  the  morbid  process  to  it.  Amongst  the  lesions  which 
cause  paralysis  may  be  mentioned  swelled  lymphatic  glands, 
abscess  or  infiltration  of  the  cellular  tissue  in  the  neighbourhood 
of  the  stylo-mastoid  foramen,  inflammation  abscess  and  tumours 
of  the  parotid  gland,  and  deep-seated  ulcerations  and  cicatrices 
such  as  occur  after  scrofulous  abscesses  of  the  glands. 

Various  diseases  of  the  ear  may  also  cause  facial  paralysis, 
and  of  all  the  causes  of  this  affection  suppurative  otitis  interna, 
followed  by  destructive  changes  in  the  temporal  bone,  is  the 
most  frequent.  Bony  tumours  and  neoplastic  formations  of  all 
kinds  proceeding  from  the  internal  ear  may  also  lead  to  com- 
pression and  destruction  of  the  nerve.  Primary  disease  of  the 
facial  nerve  is  rarely  observed  as  a  complication  of  or  sequel  to 
acute  febrile  diseases  such  as  diphtheria  and  variola,  but  is  more 

*  Hewitt  (Prescott).    Holmes'  system  of  surgery.    Vol.  II.,  1861,  p.  177. 
^  Landouzy.     L'hemiplegie  faciale  chez  les   nouveau-n^s.     Paris,   1839.     See 
Arch,  g^n^r.  de  Med.,  3e  S6ne,  Tome  VI.,  1839,  p.  397. 


DISEASES   OF  THE  MOTOR  CRANIAL   NERVES.  473 

frequent  as  a  secondary  result  of  these  affections  from  disease  of 
the  temporal  bone.  Syphilitic  periostitis,  meningitis,  exostoses, 
and  gummata  at  the  base  of  the  skull,  and  in  the  temporal  bone, 
brain,  or  the  sheath  of  the  nerve  itself  very  frequently  implicate 
the  facial  nerve.^  Some  persons  appear  to  manifest  a  predis- 
position to  this  form  of  paralysis.  Eulenburg^  mentions  the  case 
of  a  young  man  under  his  care,  who  suffered  twice  from  right- 
sided,  and  thrice  from  left-sided  facial  paralysis  of  a  very  obstinate 
character. 

Facial  paralysis  is  rare  as  a  symptom  of  disease  of  the  spinal 
cord,  but  it  may  occur  when  the  disease  progresses  as  far  as  the 
upper  end  of  the  medulla.  The  facial  nucleus  may,  for  instance, 
be  implicated  in  acute  ascending  paralysis  of  the  cord,  and 
paralysis  of  the  nerve  may  also  occur  in  tabes  dorsalis,^  and  as  a 
rare  complication  of  tetanus.* 

§  249.  Symptoms. — The  onset  of  facial  paralysis  differs  ac- 
cording to  its  cause.  It  appears  suddenly  when  it  results  from  a 
traumatic  lesion  of  the  nerve,  and  when  it  is  caused  by  exposure 
to  cold  the  patient  is  usually  surprised  to  find  one  side  of  his 
face  paralysed  in  the  morning.  When  the  paralysis  results  from 
disease  which  invades  the  nerve  secondarily,  either  by  gradual 
compression  or  by  altering  its  texture,  the  paralytic  symptoms 
become  slowly  and  gradually  developed,  and  spread  from  branch 
to  branch  of  the  nerve.  Premonitory  symptoms  may  be  ex- 
perienced for  some  days  before  the  appearance  of  the  paralysis ; 
these  consist  of  pain  on  the  side  of  the  face  which  is  subsequently 
paralysed,  noises  in  the  ear,  deafness,  and  abnormal  sensations  of 
taste  on  the  same  side. 

The  symptoms  of  complete  unilateral  facial  paralysis  are  very 
characteristic.  The  paralysed  side  of  the  face  loses  its  wrinkles 
and  furrows,  and   appears  smooth,  flaccid,   and  expressionless. 

^  See  Dixon.  "  Two  cases  of  paralysis  from  syphilitic  neuromata  of  the  intra- 
cranial nerves."    Medical  Times  and  Gazette,  Vol.  II.,  1858,  p.  419. 

^  Eulenburg  (A.).  Lehrbuch  der  Nervenkrankheiten.  Auii,  2,  Theil  II.,  1878, 
p.  108. 

^  Jean  (A.).  "Troubles  de  la  0™^  et  de  la  7™®  paires  dans  le  cours  de  I'ataxie 
locomotrice."  Bull  Soc.  Anat.  de  Par.,  1875,  1,  812;  and  Progres  Me'd.,  Paris, 
Tome  IV.,  1876,  p.  400. 

*  Hidke  and  Williams.  "Tetanus  with  facial  paralysis."  Medical  Press  and 
Circular,  New  Series,  Vol.  XXXIII.,  1882,  p.  25. 


474  DISEASES   OF  THE  MOTOR  CRANIAL   NERVES. 

From  the  loss  of  muscular  tone  the  paralysed  side  falls  to  a  lower 
level  than  the  healthy  one,  and  this  distortion  is  much  increased 
when  the  facial  muscles  are  called  into  action  during  smiling  and 
talking.  On  the  paralysed  side  the  patient  cannot  wrinkle  his 
forehead  or  elevate  his  eyebrow ;  he  is  unable  to  close  his  eye, 
and  when  he  attempts  to  do  so  the  eyeball  is  observed  to  roll 
upwards  and  inwards,  or  occasionally  upwards  and  outwards. 
Owing  to  paralysis  of  Horner's  muscle,  the  tears  cannot  enter 
the  lachrymal  canal,  and  therefore  flow  over  the  cheek.*  The 
power  of  winking  is  lost,  and  the  eye  remains  open  during  sleep 
(lagophthalmos),  and  being  no  longer  protected  from  the  contact 
of  foreign  particles,  it  often  becomes  irritated  and  inflamed. 
The  paralysis  in  the  region  of  distribution  of  the  upper  branches 
of  the  facial  nerve  gives  rise,  indeed,  to  the  phenomena  which 
mainly  distinguish  the  affection  caused  by  lesion  of  the  nerve  in 
its  peripheral  course,  and  by  one  situated  above  the  nucleus  of 
the  facial  in  the  cerebral  hemisphere.  As  remarked  by  Todd^  in 
describing  peripheral  facial  palsy,  "the  leading  character  of 
cases  of  facial  palsy  such  as  this  is  the  inability  to  close  the 
eyelids,  from  paralysis  of  the  orhicularis  "palpebrarum  muscle ; 
this  is  the  pathognomonic  sign  which  determines  the  particular 
nature  of  the  palsy,  and  distinguishes  it  from  the  more  serious 
cases  of  facial  palsy  which  is  dependent  on  disease  of  the  brain." 
The  nostril  on  the  paralysed  side  falls  in  during  inspiration, 
instead  of  expanding  as  it  does  in  health,  and  the  tip  of  the 
nose  is  sometimes,  as  in  a  case  now  under  my  care,  drawn  to 
the  healthy  side.  The  mouth  is  also  drawn  obliquely  over  to 
the  healthy  side,  and  the  distortion  becomes  more  pronounced 
during  all  mimetic  movements,  such  as  crying,  laughing,  and 
speaking.  Paralysis  of  the  buccinator  causes  the  cheek  to  puff 
out  in  speaking  and  during  other  expiratory  actions;  the  pro- 
nunciation of  the  labial  consonants  is  impaired;  attempts  at 
blowing  or  whistling  fail,  the  air  escaping  through  the  paralysed 
fissure  of  the  lips  ;  the  saliva  dribbles  from  the  affected  side ; 
and  food  is  apt  to  accumulate  between  the  inner  surface  of  the 
cheek  and  the  teeth. 

The  external  muscles  of  the  ear  are  also  paralysed,  but  since, 

^  Duchenne.     De  I'dlectrisation  localis^e.     Third  edit.,  Paris,  1872,  p.  853. 
*  Todd's  Clinical  Lectures,  edited  by  L.  S.  Beale.    Lond.,  1871.    p.  644. 


DISEASES   OF   THE  MOTOR  CRANIAL   NERVES.  475 

in  the  majority  of  people,  these  muscles  are  not  under  voluntary 
control,  impairment  of  movement  in  them  is  not  readily  detected. 
Paralysis  of  the  platysma,  of  the  posterior  belly  of  the  digastric,, 
and  of  the  stylo-hyoid  muscles  can  sometimes  be  demonstrated. 

If  the  lesion  of  the  nerve  is  situated  above  the  geniculate 
ganglion,  the  levator  palati  and  azygos  uvulae  become  paralysed, 
and  consequently  the  soft  palate  on  the  side  corresponding  to 
the  facial  paralysis  hangs  loosely  downwards,  occupies  a  lower 
position  than  on  the  sound  side,  and  manifests  diminished  action 
on  reflex  irritation  and  in  phonation.  The  uvula  is  also  dis- 
torted ;  it  is  curved  to  one  side  and  somewhat  forwards,  the  tip 
being  sometimes  directed  towards  and  sometimes  away  from  the 
paralysed  side.^  This  condition  will  be  discussed  more  at  length 
when  the  various  forms  of  paralysis  of  the  muscles  of  the  soft 
palate  are  under  consideration. 

If  the  facial  nerve  is  diseased  above  the  point  where  the 
branch  to  the  stapedius  is  given  off  (Fig.  46,  3)  that  muscle 
becomes  paralysed,  and  the  membrana  tympani  is  rendered 
unduly  tense  by  the  over-action  of  the  tensor  tympani  muscle. 
The  researches  of  Lucse^  have  shown  that  this  condition  causes 
an  abnormal  acuteness  of  hearing  of  all  musical  tones,  or  some- 
times an  abnormal  power  of  perceiving  deep  notes,  and  is  often 
accompanied  by  a  subjective  sound  of  high  pitch.  Roux,^  speak- 
ing of  an  attack  of  facial  paralysis,  from  which  he  himself  suffered, 
mentions  a  painful  vibration  of  the  tympanic  membrane  on  the 
affected  side  for  moderately  strong  sounds.  If,  therefore,  abnor- 
mal acuteness  of  hearing  accompanies  facial  paralysis,  it  may  be 
inferred  that  the  facial  nerve  is  affected  above  the  point  where 
the  little  branch  for  the  stapedius  is  given  off. 

It  is  scarcely  necessary  to  add  that  the  auditory  and  facial 
nerves  may  be  simultaneously  affected  by  diseases  at  the  base  of 

^Sanders.  "On  paralysis  of  the  palate  in  facial  palsy."  Edinburgh  Medical 
Journal,  1865,  p.  141.  See  also  Ziemssen.  "  Ueber  Labmung  von  Gebirnnerven 
durch  Affectionen  an  der  Basis  cerebri."  Virchow's  Archives,  Bd.  XIII.,  1858. 
p.  225. 

*  Lucse  (A.).  "Die  Accommodation  und  die  Accommodations-storungen  des 
Ohres."  Berlin  Klin.  Wochenschrift,  Bd.  XI.,  1874,  pp.  163,  187,  and  199.  See 
also  Landouzy.  "Exaltation  de  I'ouie  dans  la  paralysie  faciale."  Comptes  rendu 
hebd.  de  I'Acad.  du  Sciences,  Tome  XXXI.,  1850,  p.  717.  And  Hitzig.  ''Beitrage 
zur  Kentstniss  der  peripheren  Lahmung  des  Facialis."  Berl.  Klin.  Wochenschr., 
1869,  p.  18. 

^  See  Grasset  (J.).    Maladies  du  Systeme  Nerveux.    Tome  II.,  1879,  p.  314. 


476  DISEASES  OF  THE  MOTOR  CRANIAL  NERVES. 

the  brain,  in  the  meatus  auditorius  internus,  or  in  the  middle 
ear  and  the  adjoining  parts  of  the  temporal  bone.  When  that 
is  the  case,  the  facial  paralysis  is  accompanied  by  complete  deaf- 
ness of  the  ear  on  the  affected  side. 

If  the  lesion  of  the  facial  nerve  be  situated  anywhere  between 
the  geniculate  ganglion  and  the  point  of  origin  of  the  chorda 
tympani  from  the  facial,  the  sense  of  taste  in  the  lateral  half 
of  the  anterior  two-thirds  of  the  tongue  will  be  abolished,  while 
it  will  remain  unaffected  when  the  lesion  is  situated  at  the 
base  of  the  brain  above  the  ganglion,  or  below  the  point  where 
the  chorda  tympani  leaves  the  facial  {Fig.  46,  2).  The  disorder 
of  taste  consists  of  diminution  or  abolition  of  the  gustatory  sense 
for  acid,  sweet,  or  saline  substances  in  the  anterior  two-thirds  of 
the  tongue  on  the  affected  side.  Disease  of  the  secretory  fibres 
of  the  chorda  tympani  causes  diminution  of  the  salivary  secre- 
tion on  the  paralysed  side,  the  patients  often  complaining  of  an 
abnormal  dryness  of  that  side  of  the  mouth. 

Diminution  of  the  sense  of  smell  has  occasionally  been  observed 
on  the  paralysed  side.  This  is  caused  partly  by  dryness  of  the 
nostril  on  account  of  the  insufficient  discharge  of  tears,  and 
partly  by  interference  with  the  access  of  air  to  the  olfactory 
chambers  from  paralysis  of  the  levator  alse  nasi  and  the  com- 
pressor naris. 

In  all  cases  of  isolated  paralysis  of  the  facial  the  tongue  lies 
straight  on  the  floor  of  the  mouth,  and  does  not  deviate  when 
protruded.  There  is  no  paralysis  of  the  tongue,  but  an  apparent 
deviation  on  protrusion  occurs,  because  the  affected  angle  of  the 
mouth  is  drawn  over  to  the  healthy  side. 

The  sensibility  of  the  paralysed  side  of  the  face  is  generally 
normal.  When,  however,  the  peripheral  divisions  of  the  nerve 
are  affected,  branches  of  the  fifth  are  usually  implicated  in 
the  disease,  and  there  will  be  corresponding  disturbances  of 
sensibility. 

The  rejlex  movements  are  abolished  in  the  paralysed  muscles 
in  all  cases  of  peripheral  origin ;  but  in  paralysis  of  central 
origin,  more  especially  when  the  disease  is  situated  in  the  hemi- 
spheres, reflex  irritability  is  completely  preserved. 

Associated  movements  are  likewise  abolished  at  first  in  peri- 
pheral and  preserved  in  central  paralysis. 


DISEASES   OF   THE  MOTOR   CRANIAL   NERVES.  477 

The  electrical  reactions^  of  the  paralysed  nerves  and  muscles 
have  been  carefully  studied  in  the  form  which  has  been  called 
rheumatic  facial  paralysis.  In  slight  and  transitory  cases  the 
electrical  reactions  remain  normal,  or  only  become  slightly 
diminished,  but  in  all  aggravated  cases  the  affected  nerve  and 
muscles  manifest  the  "  reaction  of  degeneration." 

In  traumatic  paralysis  of  the  facial  nerve,  and  in  that  which 
results  from  severe  compression,  such  as  is  caused  by  tumours  at 
the  base  of  the  brain,  the  "  reaction  of  degeneration  "  appears  in 
its  typical  form.  In  paralysis,  from  disease  in  or  near  the  facial 
nucleus,  as  in  bulbar  paralysis,  a  simple  and  moderate  diminu- 
tion of  the  electric  excitability  occurs  in  the  nerve  and  muscles 
when  the  paralysis  has  lasted  for  some  time. 

In  paralysis  from  lesion  above  the  pons,  the  electric  excitability 
is  usually  unaltered,  but  occasionally  a  slight  increase  may  be 
observed. 

§  250.  Diplegia  Facialis,  or  bilateral  facial  paralysis,  deserves 
special  mention.  A  case  of  this  affection  was  recorded  by  Chris- 
tison  in  183V  and  by  Bell  in  1836,^  while  Davaine*  wrote  an 
important  monograph  on  the  subject  in  1852;  the  disease  has 
been  studied  since  that  time  by  Wachsmuth,^  Pierreson,^  Bar- 
winkel,^  and  others. 

The  disease  often  results  from  a  simultaneous  lesion  of  both 
facial  nerves,  such  as  compression  by  a  tumour,  where  they  are 
close  together  at  the  base  of  the  cranium,  or  in  their  course 
through  the  medulla  oblongata  and  pons.     It  is,  however,  most 

'  Erb.  "  Zur  pathologic  und  pathologischen  Anatomie  periphprischer  Para- 
lyaen."  Deutsches  Arch.  f.  klin.  med.,  Bd.  IV.,  1868,  p.  535  ;  Bd.  V.,  1869,  p.  42. 
Ibid.  "Zur  Casuistik  der  Nerven- und  Muskelkrankheiten,"  Bd.  VII.,  1870; 
"Ueber  rheumatische  Facialislahmungen,  Bd.  XV.,  1874,  p.  6;  and  Ziemssen's 
Cyclopaedia  of  medicine,  Vol.  XI.,  1876,  p.  489. 

*  Christison.  "  Cases  of  paralysis  of  individual  nerves  of  the  face."  The  Lon- 
don Medical  Gazette,  Vol.  XV.,  1834-5,  p.  60. 

^ Bell  (Sir  C).  The  nervous  system  of  the  human  body.  Third  Edit.,  1836, 
p.  326. 

*  Davaine.  De  la  paralysie  generale  ou  partielle  des  deux  nerfs  de  la  Septieme 
paire.     Paris,  1852. 

'  Wachsmuth.  Ueber  progressive  Bulbar-Paralyse  und  die  Diplegia  facialis. 
Dorpat,  1864. 

"  Pierreson.  "Deladipl(^giefaciale."  Arch,  g^n^r.  de  m^d.,  VP  Serie,  Tome X., 
1867,  Vol.  II.,  pp.  159  and  296. 

'  Barwinkel.  "Zur  Casuistik  der  doppelseitigen  Facial-lahmungen."  Arch.  f. 
Heilkunde,  Bd.  VIIL,  1867,  p.  7L 


478  DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 

frequently  observed  in  connection  with  progressive  bulbar  para- 
lysis. A  curious  case  has  been  recorded  by  Romberg*  and 
Magnus,  in  which  the  patient  had  two  attacks  of  left  hemiplegia, 
with  aphasia  and  bilateral  facial  paralysis.  At  the  post-mortem 
a'  hsemorrhagic  cyst  was  found  "at  the  external  edge  of  the  right 
hemisphere  of  the  cerebrum,  where  the  anterior  lobe  adjoins  the 
middle  one."  The  lesion  was  evidently  situated  in  the  posterior 
part  of  the  second  and  third  frontal  convolutions  of  the  right 
hemisphere,  so  that  the  cortical  centres  for  the  movements  of 
the  opposite  side  of  the  face  and  of  the  tongue  were  destroyed. 
The  remarkable  feature  of  this  case  was,  not  that  aphasia  was 
associated  with  left  hemiplegia,  which  is  not  unusual,  but  that 
the  mimetic  movements  of  both  sides  of  the  face  were  governed 
from  one  hemisphere  of  the  brain.  Bilateral  paralysis  of  the 
facial  has  been  observed  to  arise  from  exposure  to  cold,  from 
wounds  affecting  both  temporal  bones,  from  bilateral  otitis  in- 
terna, and  from  caries  of  the  temporal  bones.^ 

Sym'ptoms. — In  facial  diplegia  the  immobility  which  is  present 
on  one  side  in  the  unilateral  affection  now  appears  on  both  sides; 
but  the  oblique  position  of  the  chin,  mouth,  and  nose  is  absent. 
The  face  is  smooth,  fixed,  and  expressionless,  even  when  the 
emotions  are  powerfully  excited,  and  the  patient,  in  the  apt 
language  of  Romberg,  "laughs  and  cries  as  from  behind  a  mask." 
When  the  lesion  implicates  all  the  branches  of  both  nerves  the 
patient  is  unable  to  wink  or  close  either  eye,  and  the  tears  flow 
over  both  cheeks.  Both  cheeks  are  flaccid  and  puff  out  during 
expiratory  acts;  mastication  is  imperfectly  performed,  owing  to 
the  food  lodging  between  the  teeth  and  cheeks ;  some  diffi- 
culty is  also  experienced  in  swallowing,  due  to  paralysis  of  the 
soft  palate  and  of  the  stylo -hyoid  and  digastric  muscles ;  the 
saliva  dribbles  when  the  head  is  bent  forwards;^  taste  is 
often  abolished  in  the  anterior  part  of  the  tongue;*  and  the 

'  Romberg.     Op.  clt.,  Vol.  IT.,  1853,  p.  278. 

"^  See  Hutchinson.  "Paralysis  of  the  portio  dura  on  both  sides  from  disease  of 
the  temporal  bones."  Medical  Times  and  Gazette,  Vol.  II.,  1860,  p.  58.  Also 
Hutchinson  and  Jackson  (Hughlings).  "Cases  of  paralysis  of  the  portio  dura." 
Medical  Times  and  Gazette,  Vol.  II.,  1861,  p.  607. 

*  See  Cuming  (James).  "  A  case  of  diplegia."  British  Medical  Journal,  Vol.  II. , 
1879,  p.  1017. 

■*  Nixon  (C.  J.).  "Double  facial  paralysis,  with  some  remarks  upon  the  nerves 
of  taste."    The  Dublin  Journal  of  Medical  Science,  Vol.  LXII.,  1876,  p.  103. 


DISEASES   OF  THE  MOTOR  CRANIAL   NERVES.  479 

voice  has  a  nasal  tone,  and  fluids  readily  escape  through  the 
nose,  during  attempts  at  deglutition,  from  paralysis  of  the  soft 
palate.  The  nostrils  fall  in  during  inspiration,  causing  a  con- 
siderable amount  of  discomfort  and  difficulty  in  breathing.  The 
influence  of  the  facial  nerves  on  respiration  is  best  exemplified 
in  animals  like  the  horse,  with  very  mobile  nares,  and  in  which 
section  of  both  facials  has  been  known  to  have  caused  asphyxia. 
Articulation  is  greatly  impaired,  as  manifested  by  inability  to 
pronounce  the  vowels  "o"  and  "u"  and  the  labial  consonants. 
When  the  chorda  tympani  nerves  are  implicated  in  the  lesion 
the  abnormal  dryness  of  the  mouth  may  cause  considerable  dis- 
tress to  the  patient  ',^  and  paralysis  of  the  stapedii  muscles  may 
produce  disorders  of  hearing,  without  the  auditory  nerves  being 
involved  in  the  disease. 

§  251.  Course,  Duration,  and  Terminations. — The  course  of 
facial  paralysis  varies  greatly,  according  to  its  cause.  In  slight 
rheumatic  cases  the  paralysis  disappears  in  a  few  weeks  without 
leaving  a  trace  behind.  In  more  protracted  cases  secondary 
contracture  is  apt  to  occur  in  the  affected  muscles.  It  begins  in 
the  course  of  the  third  or  fourth  month  as  a  slight  tonic  contrac- 
tion of  the  muscles  at  the  angle  of  the  mouth,  which  is  drawn 
upwards  and  outwards  to  the  affected  side,  and  remains  fixed  in 
that  position.  The  naso-labial  fold  becomes  again  distinctly 
marked,  and  the  cheek  is  tense  and  firmly  pressed  against  the 
teeth,  and  when  the  orbicularis  palpebrarum  is  implicated  the 
palpebral  fissure  becomes  narrower,  and  the  face  assumes  a 
peculiar  and  characteristic  aspect. 

Spontaneous  movements  may  occur  in  the  muscles  during 
recovery.  These  movements  consist  of  twitching  of  some  of  the 
muscles,  which  may  sometimes  be  so  intense  as  to  simulate 
convulsive  tic. 

These  contractions  occur  sometimes  when  the  patient  is  quiescent, 
while  at  other  times  they  appear  as  associated  movements.  "When  an 
attempt  is  made  to  close  the  eye,  for  instance,  the  angle  of  the  mouth  is 
drawn  outwards  and  upwards  ;  and,  conversely,  when  an  attempt  is  made 
to  draw  the  angle  of  the  mouth  to  one  side,  the  fissure  of  the  Hd  contracts, 

*  Ward  and  Comer.  "  Cases  illustrative  of  certain  points  in  the  diagnosis,  &c., 
of  facial  paralysis."    Medical  Times  and  Gaaette,  Vol.  I.,  1858,  p.  427. 


480  DISEASES   OF  THE  MOTOE  CRANIAL  NERVES. 

while  the  zygomatici  contract  on  attempting  to  elevate  the  eyebrow.  In  a 
case  of  peripheral  facial  paralysis,  under  my  observation  at  present,  all  these 
associated  movements  are  well  seen.  When  the  patient  puts  his  tongue 
out  and  roUs  it,  by  request,  into  a  tubidar  form,  to  show  that  it  is  not 
paralysed,  the  affected  orbicular  contracts,  so  that  the  eye  becomes  closed  to 
a  greater  extent  than  it  does  during  a  voluntary  effort  to  close  both  eyes. 
The  normal  eyehd  remains  immovable  dm-ing  this  time.  The  eyehd  on  the 
paralysed  side  moves  or  falls  downwards  even  lower  than  the  other  during 
downward  rotation  of  the  eyeballs. 

Contractions  may  also  occur  in  a  reflex  manner,  either  through  the  fifth 
by  touching  the  skin  or  eyelashes,  or  through  the  optic  nerve  by  making  a 
rapid  movement  towards  the  eye.  These  associated  movements  have  been 
carefully  studied  by  Hitzig.^ 

Traumatic  paralyses  are,  as  a  rule,  very  protracted.  In  a  few 
favourable  cases  recovery  takes  place  in  the  course  of  four  to  six 
months,  but  it  is  frequently  very  incomplete,  and  the  paralysis 
often  remains  for  life. 

In  paralysis  from  pressure,  and  in  other  peripheral  paralyses, 
such  as  those  resulting  from  otitis  interna,  neuritis,  and  syphilis, 
the  course  of  the  affection  varies  with  the  nature  of  the  lesion 
and  the  severity  of  the  case. 

§  252.  Diagnosis. — The  diagnosis  presents  no  difficulty  except 
in  the  slighter  forms  of  the  affection.  In  these,  want  of  symmetry 
may  be  detected  in  the  action  of  the  muscles  of  the  two  sides 
by  careful  attention  to  the  play  of  the  features  under  varying 
emotions,  and  by  testing  the  finer  and  more  complicated  move- 
ments, such  as  those  engaged  in  pronouncing  difficult  words, 
whistling,  showing  the  teeth,  and  various  other  actions.  Con- 
siderable difficulty  is  experienced  in  diagnosing  facial  paralysis 
in  infants  ;  the  principal  signs  to  be  depended  on  are  distortion 
of  the  face  when  the  child  cries,  difficulty  of  sucking,  and  the 
presence  of  lagophthalmos  during  sleep. 

Erb^  lays  down  very  careful  and  precise  rules  for  the  diagnosis  of  the 
seat  of  the  lesion,  of  which  the  following  is  a  summary  : — 

'  Hitzig  (E. ).  "  Ueber  die  AufFassung  einiger  Anomalieen  der  Muskel-inner- 
vation."    Arch.  f.  Psychiatrie,  Bd.  III.,  1872,  pp.  312  and  601. 

^  Erb  (W.).  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,  Vol.  XL, 
1876,  Tp.  510  etsequ.  See  also  Itosenthal  (M.).  "Ueber  Characteristik  der  verschie- 
denen  Arten  von  Gesichtslahniungen."  Wiener  Medizinische  Presse,  1868,  pp.  345, 
369,  418,  477,  501,  548,  569,  596,  and  622. 


DISEASES   OF  THE  MOTOE   CRANIAL   NERVES.  481 

Peripheral  Facial  Paralysis. — Implication  of  all  the  external  branches 
of  the  nerve ;  lagophthahnos,  especially  during  sleep ;  atrophy  of  the 
paralysed  muscles  ;  the  presence  of  the  reaction  of  degeneration  ;  absence 
of  reflex  and  associated  movements ;  the  presence  of  external  wounds  or 
other  injury  in  the  ^^cinity  of  the  nerve  ;  disease  of  the  organs  adjoining 
the  jDeripheral  part  of  the  nerve,  as  of  the  parotid  gland,  the  internal  ear, 
or  the  temporal  bone  ;  imphcation  of  other  nerves  at  the  base  of  the  brain ; 
and  absence  of  characteristic  cerebral  sjanptoms. 

Cerebral  Facial  Paralysis. — The  branches  of  the  nerve  distributed  to 
the  upper  part  of  the  face  not  being  implicated  in  the  disease ;  closure 
of  the  eye  during  sleep  ;  preservation  of  reflex  acts ;  absence  of  atrophy 
of  the  muscles  and  of  the  reaction  of  degeneration ;  and  the  presence 
of  other  cerebral  symptoms,  such  as  vertigo,  sensory  disturbances,  hemi- 
plegia, weakness  of  the  tongue,  disorders  of  speech,  and  considerable 
difl&culty  in  swallowing.  Straus^  has  foimd  that  pilocarpine  does  not 
cause  sweating  of  the  paralysed  side  of  the  face  in  cases  of  peripheral  lesion 
of  the  nerve,  while  sweating  occm-s  in  the  usual  manner  on  the  paralysed 
side  in  cases  of  cerebral  disease ;  he  proposes  to  employ  the  subcutaneous 
injection  of  pilocarpine  as  an  aid  to  diagnosis. 

Each  of  these  main  divisions  may  be  subdivided  into  several  groups. 

(A)  Peripheral  Paralysis. 

(1)  If  the  lesion  be  situated  external  to  the  Fallopian  canal,  the  muscles 
of  the  face  are  alone  paralysed. 

(2)  If  the  lesion  be  situated  in  the  Fallopian  canal,  but  below  the  point 
at  which  the  chorda  tympani  is  given  off,  the  muscles  of  the  external  ear 
are  paralysed  in  addition  to  those  of  the  face. 

(3)  If  the  lesion  be  situated  between  the  point  at  which  the  chorda 
t^Tnpani  is  given  oJ0F  and  the  point  of  origin  of  the  small  branch  to  the 
stapedius,  there  are,  in  addition  to  the  symptoms  already  mentioned, 
abohtion  of  taste  on  the  anterior  two-thirds  of  the  tongue  and  diminution 
of  the  sahvary  secretion  of  the  aftected  side. 

(4)  If  the  lesion  be  situated  between  the  point  of  origin  of  the  nerve  to 
the  stapedius  and  the  geniculate  ganglion,  the  same  symptoms  are  present 
along  with  abnormal  acuteness  of  hearing. 

(5)  If  the  geniculate  ganglion  itself  is  diseased,  aU  the  previous  signs 
are  present,  and  in  adchtion  paralysis  of  the  soft  palate  and  distortion  of 
the  uvula. 

(6)  If  the  lesion  is  situated  in  the  nerve  above  the  geniculate  ganghon, 
all  the  previous  signs  are  present  with  the  exception  of  the  disorder  of  the 
sense  of  taste.  The  auditory  nerve  is  also  frequently  implicated,  and  then 
there  is  dulness  of  hearing  on  the  affected  side. 

'  Straus  (J.).  "  Des  modifications  dans  la  sudation  de  la  face  provoquee  a  I'aide 
de  la  pilocarpine,  comme  un  nouveau  signe  pouvant  servir  au  diagnostic  differentiel 
des  divers  formes  de  paralysie  faciale,"    Gaz.  Med.  de  Paris,  1880.     Nos.  2-5. 

VOL.  I.  FF 


X- 


482  DISEASES   OF  THE  MOTOR  CRANIAL  NERVES. 


(B)  Intracranial  Paralysis. 

(1)  Lesion  of  the  facial  nucleus  gives  rise  to  complete  paralysis  of  the 
facial  nerves,  paresis  of  the  velum  palati,  simple  diminution  of  electrical 
excitability,  but  no  gustatory  disturbances.  That  the  lesion  is  situated  in 
the  medulla  is  rendered  more  certain  if  the  hypoglossal,  spinal  accessory, 
vagus,  trigeminus,  or  the  abducens  are  aflfected.  Tumour  of  the  middle 
pedimcle  of  the  cerebellum  may  grow  towards  the  pons,  and  cause  facial 
paralysis  on  the  same  side  as  the  lesion.  In  these  cases  the  paralysis  of 
the  face  is  associated  with  staggering  gait,  with  tendency  to  faU  to  the  side 
of  the  lesion,  and  absolute  deafness  of  that  side,  because  the  auditory  hes 
nearer  to  the  cerebellum  than  the  facial  nerve,  and  it  suffers  compression 
first.  If  the  tumour  is  situated  near  the  nucleus  of  the  facial,  but  in  the 
course  of  the  outgoing  fibres,  complete  paralysis  of  the  facial  is  hable  to 
be  associated  with  paralysis  of  the  external  rectus  of  the  same  side  and 
with  partial  deafness,  the  latter  being  rarely  so  complete  as  it  is  when  the 
tumour  gi'ows  towards  the  facial  from  the  middle  peduncle  of  the  cere- 
bellum. The  diagnosis  between  progressive  bulbar  paralysis  and  facial 
paralysis  from  a  coarse  lesion  of  the  pons  will  be  subsequently  considered. 

(2)  When  the  lesion  is  situated  in  the  lower  and  middle  regions  of  the 
pons  there  is  complete  paralysis  of  the  facial  branches  and  paresis  of  the 
velum  palati  on  the  same  side  as  the  lesion,  and  paralysis  of  the  extremi- 
ties on  the  opposite  side  of  the  body,  or  alternate  paralysis.  When  the 
lesion  is  situated  in  the  upper  part  of  the  pons,  above  the  decussation  of 
the  fibres  which  connect  the  facial  nuclei  with  the  posterior  part  of  the 
second  frontal  convolutions  of  the  cortex,  the  paralysis  of  the  extremities  is 
on  the  same  side  as  that  of  the  face.  Diseases  of  the  pons  may  exert 
pressure  on  the  facial  nerves  at  the  base  of  the  brain,  and  thus  induce 
some  of  the  symptoms  of  peripheral  paralysis  of  the  nerve. 

(3)  When  the  disease  is  situated  above  the  pons  in  one  of  the  crura  or 
hemispheres  there  are  paralysis  of  the  lower  facial  branches  only,  paresis 
of  the  velum  palati,  and  paralysis  of  the  extremities  on  the  side  opposite 
the  lesion. 

The  diagnosis  of  the  nature  of  the  lesion  must  ]>e  based  on  general 
pathological  considerations. 

§  253.  Prognosis. — The  prognosis  depends  upon  the  nature 
of  the  primary  lesion  which  has  induced  the  paralysis.  The  most 
unfavourable  cases  are  those  which  result  from  the  pressure  of 
incurable  tumours,  from  caries  of  the  temporal  bone,  fractures  of 
the  bone,  gunshot  injuries,  bulbar  paralysis,  and  tumours  of  the 
brain.  Those  which  result  from  apoplexy  and  embolism  generally 
disappear  in  a  few  weeks.  In  syphilitic  facial  paralysis  the  prog- 
nosis is  favourable,  although  it  is  not  always  curable.     When  the 


DISEASES   OF  THE  MOTOR  CRANIAL   NERVES.  483 


• 


paralysis  results  from  otitis  interna  and  parotitis  the  prognosis 
depends  upon  the  curability  of  these  afifections.  Perfect  recovery 
usually  takes  place  after  simple  section  of  the  nerve  or  of  its 
branches.  In  rheumatic  facial  paralysis  the  prognosis  mainly 
depends  upon  the  character  of  the  electrical  reactions  obtained.^ 

If  the  electrical  irritability  of  the  paralysed  nerve  and  muscles 
be  normal  at  the  end  of  the  first  week,  recovery  takes  place  in 
two  or  three  weeks ;  and  if  the  reaction  to  both  currents  be 
slightly  diminished  at  the  end  of  the  week,  recovery  may  be 
expected  in  the  course  of  from  four  to  six  weeks ;  but  if  the 
electrical  irritability  be  greatly  diminished  or  completely  lost  at 
the  end  of  the  first  week,  the  disease  will  last  at  least  several 
months,  and  subsequent  contractures  will  take  place. 

Facial  paralysis  of  new-born  infants  is  generally  very  transitory, 
its  duration  varying  from  a  few  hours  to  a  few  weeks.  Duchenne' 
has  observed  two  cases  in  which  the  paralysis  persisted  in  the 
one  to  5^  and  in  the  other  to  15  years  of  age;  but  such  cases 
are  exceptional 

§  254.  Treatment — An  endeavour  must  first  be  made  to 
remove  the  cause  of  the  afi'ection.  When  the  disease  results 
from  otitis  interna  and  fractures  of  the  skull,  the  usual  surgical 
remedies  must  be  adopted.  In  syphilitic  paralysis  mercury  or 
iodide  of  potassium  must  be  prescribed.  In  rheumatic  paralysis 
antiphlogistic  treatment  must  first  be  adopted,  consisting  of  the 
vapour  bath,  or  a  simple  warm  bath  with  subsequnt  warm  local 
fomentations.  Blistering  should  not  be  used  until  the  disease 
has  become  more  or  less  chronic.  When  there  is  neuritis  the 
galvanic  current  may  be  employed  at  an  early  period,  the  best 
method  being  the  stabile  application  of  the  anode  to  the  mastoid 
process  of  the  affected  side,  the  cathode  being  placed  on  the 
opposite  side.  After  a  time  the  cathode  and  anode  may  be 
alternately  applied  on  the  diseased  side. 

In  the  later  stages  of  the  affection  the  application  of  elec- 
tricity forms  the  best  direct  treatment.*    In  the  slighter  forms  of 

1  See  De  Watteville  (A.).  "  On  facial  paralysis  from  cold,  with  special  reference 
to  its  prognosis."  The  Practitioner,  Vol.  XXIV.,  1880,  p.  353.  And  Smith 
(W.  G.).     The  Dublin  Journal  of  Medical  Science,  Vol.  LXV.,  1878,  p.  125. 

=  G-rasset  (J.).     Maladies  du  systfeme  nerveux,     Paris,  1879,  Tome  II.,  p.  326. 

'  See  Erb  (W.).    Handbuch  der  Electrotherapie.    II.  Halfte,  1882. 


484 


DISEASES   OF   THE  MOTOR  CRANIAL  NERVES. 


the  disease  a  moderately  strong  faradic  current  may  be  applied 
for  two  or  three  minutes,  either  daily  or  on  alternate  days. 
The  same  treatment  is  indicated  when  the  disease  is  of  somewhat 
greater  intensity,  and,  in  addition,  the  galvanic  current  may  be 
passed  through  the  mastoid  process  in  the  manner  already 
described.  When  the  reaction  of  degeneration  is  present  the 
galvanic  gives  better  results  than  the  faradic  current.  It  should 
be  applied  at  first  once  or  twice  a  week  to  the  branches  of  the 
nerve,  and  to  the  muscles,  but  as  soon  as  there  are  any  indica- 
tions of  the  return  of  motor  power  the  application  may  be  made 
more  frequently.  The  annexed  diagram  {Fig.  48)  indicates  the 
motor  points  of  the  facial  nerve. 

Fig.  48. 


M.  corrngator  supercil.  . . . 
M.  compressor  nasi  et  pyrami 

dal  nasi  

M.  orbicular,  palpebr 

M.  levator  lab.  sup.  alaeque  nasi 

M.  levator  lab.  snp.  propr.. 
M.  zygomatic,  minor  

M.  dilatat.  narium  . .  i 

I  post 

M.  zygomatic,  major  

M.  orbicvdaris  oris    

Earn.  comm.  pro  Mm.  triangu 

lar  et  levator  menti   . . . 
M.  levator  menti  

M,  quadratas  menti 

M.  triangularis  menti 

Hami  subcutan.  colli  N.  facial 
Eami  cervical,  pro  Platyamat 

M.  sternobyoideus 

M.  omohyoideus 

M.  sternotbyroideus 

M.  aternohyoideus 


M.  frontalis. 

Mm.  attrabens  et  attoUena 

auriculae. 
Mm.  retrahens  et  attoll.  anricnl. 

Mnsc.  occipitalis. 

Nerv.  facialis. 

Bam.  auricular,  poet.  prof. 

N.  facialis. 
M.  stylobyoideus. 
M.  digastricus. 
Eami  bnccales  N.  facialia. 
M.  splenius  capitis. 
Eami  subcutan.  maxill.  infer. 
Eam.  est.  N.  accessorii.  WiUisii. 
M.  sterno-cleido-mastoideus. 
M.  Cucullaris. 

M.  sterno-cleido-mastoideus. 
M.  levator  anguli  scapulse. 
N.thoracic.poat.  (Mm.rhomboidei.l 

N.  pbrenicna. 

M.  omobyoid. 

—  N.  Thoracic,  lateral. 
(M.  serrat.  magn.  i 


N  Thoiacic  ant. 
(Mm.  pectorales.) 


Eam.  plex.  brachiaUa. 

(N.  musculocutan.  et  pars 

N.  mediani.) 


Fig.  48  (after  Ziemssen).  —Motm'  points  of  face,  showing  the  position  of  the  electrodes 
in  electrisation  of  the  facial  nerves  and  muscles.  The  anode  is  placed  in  the 
mastoid  fossa,  and  the  cathode  upon  the  part  indicated  in  the  figure. 


DISEASES   OF  THE  MOTOR  CRANIAL  NERVES.  485 

When  electricity  has  proved  useless,  little  or  no  benefit  will  be 
obtained  from  the  subcutaneous  injection  of  strychnia,  stimu- 
lating linaments,  cold  and  warm  douches,  or  any  form  of  counter- 
irritation.  Iodide  of  potassium  in  large  doses  is  the  only  medi- 
cine which  appears  to  exert  a  favourable  influence  in  the  early 
stages  of  this  disease. 

Various  mechanical  means  have  been  used  in  the  treatment  of 
secondary  contractures,  such  as  traction  with  the  fingers,  and 
placing  wooden  or  indiarubber  balls  in  the  cheeks.  Faradisation 
of  the  healthy  antagonists  has  also  been  employed  as  a  means  of 
exercising  traction  on  the  affected  muscles. 

Various  operative  procedures,  such  as  subcutaneous  section  of  the 
levator  palpebrse  superioris,  and  the  operation  for  ectropion,  have 
been  undertaken  in  incurable  cases,  in  order  to  remove  distortions. 

(III.)-DIS.EASES    OF    THE    HYPOGLOSSAL    NERVE. 

The  hypoglossal  is  the  motor  nerve  of  the  tongue,  and  of  some 
of  the  muscles  of  the  neck.  Its  course,  distribution,  and  connec- 
tions are  illustrated  in  the  subjoined  diagram  {Fig.  49). 

§  255.  Spasm  of  the  Muscles  supplied  by  the  Hypoglossal 
Nerve — Lingual  Spasm. — Lingual  spasm  is  rare  as  an  inde- 
pendent affection,  but  it  is  a  common  symptom  of  hysterical 
convulsioDS,  chorea,  epilepsy,  eclampsia,  and  often  accompanies 
spasms  of  the  muscles  supplied  by  the  motor  branch  of  the  fifth, 
the  facial,  and  the  spinal  accessory  nerves,  and  trigeminal  neu- 
ralgia, and  stuttering.  It  may  result  from  meningitis,  and  from 
lesion  of  the  cortical  motor  centre  of  the  movements  of  the 
tongue,  and  tremor  of  the  tongue  is  a  symptom  of  progressive 
muscular  atrophy,  bulbar  paralysis,  and  disseminated  sclerosis. 

In  lingual  spasm,  when  the  patient  endeavours  to  speak,  the 
muscles,  innervated  by  the  hypoglossal  nerve,  are  thrown  into 
a  state  of  clonic  or  tonic  convulsions,  the  affection  being  more  or 
less  similar  to  writers'  cramp,  and  the  spasms  implicating  other 
special  movements.  Spasm  in  the  region  of  the  hypoglossal 
nerves  was  named  aphthongia  by  Fleury,^  and  in  a  case  of  the 

1  rieury.  "  Observation  d'une  forme  non  classic  de  la  lesion  de  la  parole ; 
mutite  par  paralysie  r6flexe  ou  aphthongie."  Gaz.  hebd.  de  med.  et  de  chir., 
2e  Serie,  Tome  II.,  1865,  p.  239. 


486 


DISEASES   OF  THE  MOTOR   CRANIAL  NERVES. 


affection  described  by  him  the  tongue  was  thrown  into  a  state 
of  spasm  and  fastened  to  the  hard  palate  whenever  the  patient 
endeavoured  to  speak.   Eulenburg^  quotes  several  cases  of  lingual 


Fig.  49. 


Fig.  49.  Diagram,  of  the  Hypoglossal  Nerve,  its  connections  and  branches. 
H,  Hypoglossal  nerve.  P,  Pneumogastric  nerve. 

S,  Superior  cervical  ganglion  of  the  sympathetic.  L,  Lingual  nerve. 

IC,  lie,  IIIC,  The  three  upper  eervical  nerves. 

1,  Communicating  branches  from  hypoglossal  to  ganglion  of  the  trunk  of 

the  vagus. 

2,  Connecting  filaments  with  the  loop  of  first  and  second  cervical  nervee. 

3,  Branch  to  the  sympathetic. 

4,  Descendens  noni. 

5,  Branch  from  second  and  third  cervical  nerves  (communicantes  noni). 

6,  Branch  to  thyro-hyoid. 

7,  Terminal  muscular  branches. 

8,  Communicating  branch  to  lingual  branch  of  the  fifth. 

'  Eulenburg.    Lehrbuch  der  Nervenkrankheiten.    Bd.  II.j  1878,  p.  176. 


DISEASES  OF  THE  MOTOR  CRANIAL  NERVES.  487 

spasm  observed  by  various  authors;  in  a  case  reported  by  Vallin/ 
the  tongue  was  fixed  to  the  hard  palate  by  a  tonic  spasm,  and 
in  one  observed  by  PantheP  the  sterno-hyoid,  thyro-hyoid,  and 
sterno-thyroid  muscles  were  affected  with  clonic  spasms,  which 
could  be  temporarily  suppressed  by  local  pressure  on  the 
muscles.  An  aggravated  case  of  the  affection  has  recently 
been  described  by  Mossdorf.^  In  a  boy  under  my  observation 
at  present,  who  is  the  subject  of  the  spasmodic  paralysis  of 
infancy  affecting  all  four  extremities,  the  spasmodic  action  of 
the  muscles  of  the  tongue  and  face  when  he  speaks  is  most 
painful  to  witness.  Spasms  in  the  region  of  the  hypoglossal 
nerves  are  frequently  observed  in  bilateral  athetosis  and  allied 
diseases. 

§  256.  Paralysis  of  the  Muscles  supplied  by  the  Hypoglossal 
Nerve  (Glossoplegia). 

Etiology. — Paralysis  of  the  muscles  of  the  tongue  is  frequent 
in  cerebral  affections,  but  rare  as  the  result  of  peripheral  lesions.* 
The  tongue  is  usually  implicated  in  hemiplegia  from  haemor- 
rhage, embolism,  and  other  lesions  in  the  hemispheres  and  basal 
ganglia.  Paralysis  of  the  tongue  is  also  a  symptom  of  apoplectic 
bulbar  paralysis,^  and  of  progressive  bulbar  paralysis,  either 
when  it  is  a  primary  disease  or  complicates  progressive  muscular 
atrophy.  Injury  of  the  upper  part  of  the  vertebral  column,  such 
as  fracture  of  the  atlas,  may  implicate  the  hypoglossal  nerve. 
Paralysis  of  this  nerve  may  also  occur  in  the  advanced  stage  of 
tabes  dorsalis,^  and  in  secondary  descending  sclerosis,  when  the 
ganglion  cells  of  the  hypoglossal  nuclei  are  implicated.^  The 
nerve  may  be  injured  in  its  peripheral  course  by  tumours  and 

1  Vallin  (Emile).  "  Cas  d'aphthongie  (alalie  par  trouble  de  la  motilite  de  la 
langue)."    Gaz.  hebd.  de  med.  et  de  chir.,  2^  S^rie,  Tome  II.,  1865,  p.  262. 

^  Panthel.  Deutsche  Klinik.  1855,  No.  4.  Quoted  by  Kussmaul.  Ziemssen's 
CyclopEedia  of  Medicine,  Vol.  XIV.,  1878,  p.  843. 

*  Mossdorf.  "  Ein  FaU  von  Aphthongie."  CentralbL  fur  Nervenheilkunde, 
Bd.  III.,  1880,  p.  2. 

*  Romberg.     On  diseases  of  the  nervous  system.    Vol.  II.,  1853,  p.  302. 

*  Jackson  (H.).     The  Lancet,  Vol.  II.,  1872,  p.  770. 

*  Cu£fer._  "  Sur  un  cas  de  sclerose  des  cordons^  posterieurs  ;  ataxie  locomotrice, 
avec  atrophic  de  la  main  droite  et  h^miatrophie  droite  de  la  langue."  Gaz.  m6d.  de 
Paris,  Tome  IV.,  Serie  1875,  p.  318. 

^  See  Grasset.    Maladies  du  Systeme  Nerveux.    Tome  II.,  1879,  p.  353. 


488  DISEASES   OF  THE  MOTOR   CRANIAL   NERVES. 

other  lesions  at  the  base  of  the  brain,  or  by  extracranial 
growths^  and  wounds.^ 

Symptoms. — In  unilateral  paralysis  very  little  is  observed 
when  the  tongue  is  in  a  state  of  repose,  but  when  it  is  protruded 
the  tip  is  seen  to  deviate  to  the  paralysed  side  in  consequence 
of  the  predominance  of  the  action  of  the  healthy  genioglossus 
which  directs  the  tip  of  the  tongue  to  the  opposite  side.  The 
various  movements  of  the  tongue  can  only  be  imperfectly  or  not 
at  all  performed  on  the  affected  side. 

When  the  paralysis  is  double  and  complete,  the  tongue  lies 
immovable  on  the  floor  of  the  cavity  of  the  mouth ;  it  is  relaxed, 
often  atrophied,  with  its  surface  wrinkled,  and  frequently  pre- 
senting slight  fibrillary  contractions  of  its  surface.  When  the 
tongue  is  paralysed  it  falls  backwards  in  the  cavity  of  the  mouth, 
as  the  patient  lies  on  his  back,  and  the  glottis  becomes  partially 
or  wholly  closed  by  it.  Paralysis  of  the  tongue  thus  contributes 
ito  the  production  of  stertorous  breathing  in  cases  of  apoplexy, 
and  may  even  cause  asphyxia  when  the  paralysis  is  bilateral  and 
more  or  less  complete.  It  is  important  to  remember  that  the 
temporary  paralysis  of  the  tongue  present  during  deep  chloro- 
form narcosis  may  have  the  effect  of  closing  the  glottis.^  In 
bilateral  paralysis  with  atrophy  of  the  tongue  speech  becomes 
completely  inarticulate  and  unintelligible ;  but  this  condition 
must  be  carefully  distinguished  from  dumbness,  aphonia,  aphasia, 
and  stuttering.  Singing  is  difficult  or  impossible  even  in  slight 
degrees  of  lingual  paresis.  If  the  paralysis  is  incomplete,  the 
tongue  can  be  protruded,  but  complicated  movements,  such  as 
raising  the  tip  to  the  roof  of  the  mouth,  or  rolling  the  tongue 
into  a  tubular  form,  are  impossible.  Mastication  is  to  some  extent 
interfered  with,  because  the  food  can  no  longer  be  rolled  about 
in  the  mouth  and  placed  between  the  teeth ;  whilst  deglutition 
is  impeded,  because  the  bolus  cannot  be  properly  collected  on  the 
dorsum  of  the  tongue  and  pushed  backwards  into  the  pharynx. 
The  consequence  is  that,  during  deglutition,  food  and  fluids 
regurgitate  into  the  mouth,  and  the  patient  is  annoyed  by  the 

1  Hutchinson.     Medical  Times  and  Gazette,  Vol.  I.,  1880,  p.  57. 

*  Mitchell  (S.  Weir).  Injuries  of  nerves  and  their  consequences.  Lond.,  1872. 
p.  335. 

*  See  Bowles.    Medical  Times  and  Gazette,  Vol.  I.,  1860,  p.  126. 


DISEASES   OF  THE   MOTOR   CRANIAL   NERVES.  489 

constant  accumulation  of  saliva  in  the  mouth.  Articulation 
becomes  difficult  and  indistinct,  difficulty  being  first  experienced 
in  pronouncing  the  letters  s,  sh,  1,  e,  i,  and  at  a  later  period 
k,  g,  r,  &c.  According  to  Hutchinson/  the  best  method  of  testing 
the  condition  of  the  lingualis  muscle  is  to  take  each  side  of  the 
tongue  between  the  finger  and  thumb  of  each  hand,  and  then  to 
request  the  patient  to  put  his  tongue  out.  If  one-half  is 
paralysed,  that  side  remains  soft  and  flaccid,  while  the  healthy 
side  becomes  firm  and  stiff.  In  a  patient,  aged  fifty  years,  under 
my  care  at  the  Royal  Infirmary,  the  right  half  of  the  tongue 
was  paralysed  and  atrophied ;  in  addition,  there  were  atrophic 
paralysis  of  the  anterior  group  of  muscles  of  the  right  leg,  and 
partial  paralysis  of  the  muscles  supplied  by  the  third  nerve  of 
the  same  side.  The  patient  stated  that  the  paralysis  had  come 
on  nearly  thirty  years  ago,  while  he  was  suffering  from  secondary 
syphilis  from  infection  caught  about  nine  months  previously. 
There  were  no  sensory  disturbances.  The  symptoms  corre- 
sponded in  many  respects  to  the  atrophic  spinal  paralysis  of 
adults,  or  they  might  have  been  caused  by  multiple  lesions  in 
tertiary  syphilis ;  but  if  the  statements  of  the  patient  are  trust- 
worthy, the  tertiary  period  could  not  have  been  established. 
The  case  of  an  aged  man  is  reported  by  Ballard,^  in  which 
paralysis  of  the  tongue  became  suddenly  developed.  The  chief 
symptoms  consisted  of  difficulty  of  articulation  and  inability 
to  protrude  the  tongue,  or  to  pronounce  the  labial  consonants. 
There  was  no  facial  paralysis.  A  few  days  after  the  onset 
of  the  attack  one-half  of  the  tongue  became  gangrenous 
and  sloughed,  and  it  was  subsequently  removed  by  operation 
without  any  haemorrhage  occurring.  The  patient  made  a  good 
recovery. 

Diagnosis. — The  diagnosis  of  lingual  paralysis,  as  a  rule, 
presents  no  difficulty.  The  nature  of  the  primary  lesion  must  be 
distinguished  from  the  concomitant  symptoms,  as,  for  instance, 
unilateral  paralysis  of  the  tongue  in  association  with  hemiplegia 
indicates  a  cerebral  origin ;  while  bilateral  paralysis  in  con- 
nection with  paralysis  of  the  lips  and  soft  palate  indicates  a 
bulbar  origin. 

1  Hiitcbinson  (J.).     Medical  Times  and  Gazette,  Vol.  I.,  1880,  p.  57. 
=■  Ballard.    Medical  Times  and  Gazette,  Vol.  I.,  1869,  p.  296. 


490 


DISEASES   OF   THE  MOTOR  CRANIAL   NERVES. 


Prognosis. — The  prognosis  will  depend  upon  the  nature  of  the 
primary  lesion. 

Treatment. — The  treatment  must  first  be  directed  against  the 
primary  cause  of  the  paralysis.  Electricity  is  the  most  useful 
means  of  direct  treatment.  The  galvanic  or  faradic  current  may 
be  applied  directly  to  the  tongue  or  to  the  hypoglossal  nerv©  in 
the  neck,  immediately  above  the  great  cornu  .of  the  byoid  bone. 


491 


CHAPTER   V. 


DISEASES  OF  THE  MIXED  CRANIAL  NERVES  (TRIGEMINUS, 
AND  PNEUMOGASTRIC  WITH   SPINAL  ACCESSORY). 

(I.)— DISEASES    OF    THE   TRIGEMINAL   NERVE. 

The  sensory  portion  of  the  fifth  nerve  subdivides  into  three  main 
branches,  named  respectively  the  first,  or  ophthalmic ;  the  second, 
or  superior  maxillary ;  and  the  third,  or  inferior  maxillary,  the 
last  being  joined  by  the  smaller  or  motor  root  of  the  nerve.  The 
terminal  distribution  of  the  different  subdivisions  is  represented 
in  Figs.  50  and  51 ;  while  the  course  and  branches  of  the  divi- 
sions of  the  nerve  are  shown  diagramatically  in  Figs.  52  and  53. 

§  257.  Functions. — The  sensory  fibres  of  the  nerve  confer?' 
sensibility  on  nearly  the  whole  of  the  head.  The  regions  of  the 
head  not  supplied  by  the  fifth  are:  portions  of  the  pharynx, 
palate,  root  of  the  tongue,  Eustachian  tube,  tympanic  cavity, 
and  portions  of  the  external  auditory  meatus  and  external  ear 
which  receive  branches  from  the  vagus  and  glosso-pharyngeal 
nerves;  a  portion  of  the  back  of  the  head  and  the  region  of  the 
parotid  are  supplied  by  the  cervical  spinal  nerves.  The  motor 
part  of  the  nerve  supplies  the  temporal,  pterygoid,  masseter,  and 
mylo-hyoid  muscles,  as  well  as  the  anterior  belly  of  the  digastric. 

The  lingual  branch  of  the  fifth  has  been  considered  to  be  the  special 
nerve  of  taste  for  the  anterior  two-thirds  of  the  tongue,  but  it  has  already 
been  pointed  out  that  the  fibres  presiding  over  this  function  join  it  from 
the  chorda  tympani. 

According  to  some  the  fifth  nerve  supplies  motor  fibres  to  the  dilator 
of  the  iris,  but  these  are  probably  derived  from  the  sympathetic ;  the  tensor 
tympani  and  tensor  palati  receive  motor  filaments  from  the  otic  ganglion. 

Vaso-motor  fibres,  probably  of  sympathetic  origin,  run  in  the  trigeminus 
for  the  conjunctiva  and  iris. 


492 


DISEASES   OF   THE  MIXED   CRANIAL   NERVES. 


l^eoretory  fibres  are  also  contained  in  it  for  the  laclirymal,  parotid,  and 
submaxillary  glands. 

Trophic  fibres  destined  for  the  eyeball  appear  to  be  contained  in  the 
fifth  nerve,  inasmuch  as  section  of  it  in  the  skull  causes  inflammation  and 
degeneration  of  that  organ.  It  is  also  said  to  contain  trophic  fibres  for  the 
cavities  of  the  mouth  and  nose,  because  section  of  the  nerve  occasions 
ulceration  of  the  oral  and  nasal  mucous  membrane. 

Fig.  50. 


Fig.  50,    Nerves  of  the  Face  and  Scalp  (from  Hirschfeld  and  Leveille). 


1,  Attrahens  aurem  muscle.  17, 

2,  Anterior  belly  of  occipito-frontalis.  18, 

3,  Auriculo-temporal  nerve.  19, 

4,  Temporal  branches  of  facial  nerve  20, 

(7th).  21, 

5,  Attollens  aurem  muscle.  22, 

6,  Supra- trochlear  nerve  (5th).  _  23, 

7,  Posterior  belly  of  occipito-frontalis.  24, 

8,  Supra-orbital  nerve  (5th).  25, 

9,  Retrahens  aurem  muscle.  26, 

10,  Temporal  branch  of    orbital    nerve  27, 

(5th).       _  28, 

11,  Small  occipital  nerve.  29, 

12,  Malar  branches  of  facial  nerve.  30, 

13,  Posterior  auricular  nerve  (7th). 

14,  Malar  branch  of  orbital  nerve  (5th)  31, 

(ramus  subcutaneus  raalse).  32, 

15,  Great  occipital  nerve.  33, 

16,  Infra-orbital  branches  of  facial  nerve  34, 

(7th). 


Facial  nerve  (7th). 

Nasal  nerve  (5th). 

Cervico-facial  division  of  7th. 

Infra-orbital  nerve  (5th). 

Branches  to  digastric  and  stylo-hyoid. 

Temporo-facial  division  of  7th. 

Great  auricular  nerve. 

Buccal  branches  of  facial  nerve. 

Trapezius. 

Buccinator  nerve  (5th). 

Splenius  capitis. 

Masseter. 

Sterno-mastoideus. 

Supra-maxillary  branches  of    facial 

nerve  (7th). 
Superficial  cervical  nerve. 
Mental  nerve  (5th). 
Platysma. 
Infra-maxillary  branches    of    facial 

nerve  (7th). 


DISEASES   OF  THE   MIXED   CRANIAL  NERVES.  493 

The  diseases  of  the  fifth  pair  of  nerves  may  be  divided  into 
(1)  hypersBSthesia,  (2)  anaesthesia,  (3)  neuralgia,  (4)  trophic  dis- 
orders, and  (5)  motor  disorders  of  the  trigeminus. 

(l)-HYPERiESTHESIA  OF  THE  TRIGEMINUS. 
An  increase  of  the  tactile  sensibility  in  the  region  of  the 
trigeminus  has  not  probably  been  observed,  but  the  sensibility 
to  pain  is  sometimes  so  much  increased  that  the  patient  cannot 
endure  the  slightest  touch  of  the  face.  Hyperalgesia  often 
accompanies  or  precedes  an  attack  of  neuralgia,  and  precedes 
facial  anassthesia  in  cases  of  neuritis  of  the  fifth,  or  compression 
of  the  nerve  or  conducting  paths  by  a  tumour.  The  increased 
sensibility  to  pain  is  often  accompanied  by  a  decided  diminution 
of  tactile  sensibility.  Hyperalgesia  of  the  branches  distributed 
to  the  conjunctiva  gives  rise  to  photophobia. 

(2)— ANESTHESIA  OF  THE  TRIGEMINUS. 

Anaesthesia  of  the  fifth  nerve  may  be  caused  by  central  or 
peripheral  lesions.  Apoplectic  hemiplegia  is  usually  attended 
by  a  certain  degree  of  anaesthesia  in  the  district  supplied  by  the 
trigeminus,  but  the  most  pronounced  forms  of  the  affection  are, 
as  a  rule,  caused  by  lesions  in  the  peripheral  course  of  the  nerve. 
The  peripheral  lesion  may  consist  of  primary  morbid  changes  in 
the  nerve  itself,  or  in  the  Gasserian  ganglion,  or  of  secondary 
changes  set  up  in  them  by  the  compression  of  intracranial 
tumours,  diseased  vessels  and  membranes  of  the  brain,  diseases 
and  fractures  of  the  skull,  and  wounds  of  the  head.  It  is  scarcely 
necessary  to  point  out  that  the  lesion  may  be  situated  in  any 
part  in  the  course  of  the  nerve  from  its  deep  origin  in  the  nuclei 
of  the  floor  of  the  fourth  ventricle  to  its  final  distribution. 

§  258.  Symptoms. — When  all  the  branches  of  the  nerve  are 
affected,  one  side  of  the  face,  part  of  the  ear,  the  skin  of  the 
temple  and  fore  part  of  the  head,  the  conjunctiva  coruta,  nasal 
and  oral  mucous  membranes,  the  tongue,  gums,  and  part  of  the 
pharynx  are  all  rendered  more  or  less  completely  insensitive  on 
the  affected  side ;  and  yet  violent  eccentric  pains  may  be  felt  in 
the  anaesthetic  area  (anaesthesia  dolorosa).  When  the  patient 
puts  a  cup  to  his  lips  it  gives  him  the  impression  of  being 


494  DISEASES   OF  THE  MIXED   CRANIAL  NERVES. 

broken,  as  he  can  only  feel  with  one  half  of  the  lip.  The  move- 
ments of  mastication  are  affected  when  the  motor  root  is  impli- 
cated, and  although  the  muscles  supplied  by  the  seventh  are  not 
paralysed,  yet  the  facial  movements  on  the  anaesthetic  side  are 
often  slow  and  imperfect.  When  the  anaesthesia  is  of  peripheral 
origin  reflex  actions  are  abolished. 

The  skin  of  the  face  is  cold,  and  often  of  a  bluish  colour.  The 
gums  of  the  affected  side  are  spongy,  the  mucous  membrane  of 
the  mouth  and  nose  of  that  side  may  ulcerate  and  bleed,  and 
neuro-paralytic  ophthalmia  is  apt  to  occur.  Irritation  of  the 
nasal  mucous  membrane  by  ammonia  or  snuff  does  not  excite 
a  reflex  action,  and  the  sense  of  smell  on  the  same  side  is  also 
diminished,  owing  partly  to  dryness  of  the  Schneiderian  mem- 
brane, and  partly  to  the  nutritive  changes  which  take  place  in 
it.  The  sense  of  hearing  is  unaffected  provided  the  tensor 
tympani  be  not  paralysed,  and  the  sense  of  taste  in  the  anterior 
two-thirds  of  the  anaesthetic  side  of  the  tongue  is  only  lost 
when  the  lesion  is  situated  at  the  base  of  the  skull,  or  in  the 
linsfual  branch  of  the  nerve.  The  extent  of  the  anaesthesia  will 
of  course  vary  according  to  the  seat  of  the  disease,  and  it  may 
sometimes  be  limited  to  the  area  of  distribution  of  a  single 
branch  of  the  nerve.  A  curious  case  of  complete  paralysis  of 
all  the  sensory  and  motor  branches  of  both  the  fifth  nerves  is 
reported  by  Althaus.^  There  was  complete  anaesthesia  in  the 
areas  of  distribution  of  both  nerves ;  all  the  muscles  of  masti- 
cation were  paralysed;  the  secretions  of  tears  and  saliva  were 
arrested,  but  there  was  an  increased  flow  of  conjunctival,  buccal, 
and  nasal  mucus ;  leucoma  of  both  corneae  was  present,  but  still 
the  patient  suffered  from  photophobia ;  and  the  senses  of  smell 
and  hearing  were  normal  in  acuteness,  although  the  patient 
complained  of  rushing  noises  in  his  ears,  caused  most  probably 
by  paralysis  of  the  tensor  tympani  The  sense  of  taste  appears 
to  have  been  impaired  in  the  anterior  two-thirds  of  the  tongue, 
although  the  statements  of  the  author  with  regard  to  this  point 
are,  somewhat  hesitating. 

§  259.   Diagnosis. — The   chief  difficulty   in   diagnosis   is  to 

1  Althaus  (J.).  "  On  certain  points  in  the  physiology  and  pathology  of  the  fifth 
pair  of  cerebral  nerves."    The  Lancet,  VoL  II.,  1868,  p.  729. 


DISEASES  OF  THE  MIXED  CRANIAL   NERVES.  495 

discover  the  locality  of  the  primary  lesion,  and  more  especially 
to  determine  whether  the  affection  be  of  peripheral  or  central 
origin.  The  anaesthesia  caused  by  a  central  lesion  is  not  usually 
limited  to  the  face,  but  extends  to  one-half  of  the  body;  and, 
when  caused  by  organic  disease,  it  is  generally  accompanied  by 
hemiplegia.  A  lesion  situated  in  the  upper  part  of  the  lateral 
half  of  the  medulla  oblongata  may  give  rise  to  a  crossed  hemi- 
anaesthesia,  in  which  sensation  is  lost  in  the  face,  on  one  side  of 
the  body,  and  in  the  limbs  on  the  opposite  side. 

The  following  rules  laid  down  by  Romberg^  may  be  of  use  in 
determining  the  locality  of  the  lesion  when  it  is  situated  in  the 
peripheral  course  of  the  nerves  : — 

(a)  "The  more  the  anaesthesia  is  confined  to  single  filaments  of  the 
nerve,  the  more  peripheral  will  the  seat  of  the  cause  be  found  to  be." 

(6)  "  If  the  loss  of  sensation  afiects  a  portion  of  the  facial  surface, 
together  with  the  corresponding  facial  cavity,  the  disease  may  be  assumed 
to  involve  the  sensory  fibres  of  the  fifth  pair  before  they  separate  to  be  dis- 
tributed to  their  respective  destinations ;  in  other  words,  a  main  division 
must  be  afiected  before  or  after  its  passage  through  the  cranium." 

(c)  "  When  the  entire  sensory  tract  of  the  fifth  nerve  has  lost  its 
sensation,  and  there  are  derangements  of  the  nutritive  functions  in  the 
affected  parts,  the  Gasserian  ganglion,  or  the  nerve  in  its  immediate 
vicinity,  is  the  seat  of  the  disease."  I  have,  however,  known  tumour  of 
the  pons  with  implication  of  the  fibres  of  the  fifth  nerve  to  be  associated 
with  neuro-paralytic  ophthalmia. 

(d)  "  If  the  anaesthesia  of  the  fifth  nerve  is  complicated  with  disturbed 
function  of  adjoining  cerebral  nerves,  it  may  be  assumed  that  the  cause  is 
seated  at  the  base  of  the  brain." 

§  260.  The  treatment  of  ansesthesia  of  the  fifth  nerve  must  be 
conducted  on  the  same  principles  as  that  of  other  forms  of  anees- 
thesia,  i.e.,  by  endeavouring  to  remove  the  cause,  and  by  direct 
treatment.  In  applying  electricity  to  the  face  the  usual  pre- 
cautions must  be  taken  not  to  use  too  strong  a  current. 

>      (3)-NEURALGIA  OF  THE  FIFTH  NERVE. 

Trigeminal  Neuralgia. 

Trigeminal  neuralgia  consists  of  paroxysms  of  neuralgic  pain 
in  the  region  of  distribution  of  the  fifth  nerve  or  of  some  of  its 

'  Romberg.  A  manual  of  the  nervous  diseases  of  man.  Syd.  Soc,  Vol.  I., 
Lond.,  1853,  p.  213e««e3. 


496  DISEASES   OF  THE  MIXED   CRANIAL  NERVES. 

branches.  It  is  sometimes  called  Fothergill's^  disease,  because 
be  was  the  first  author  who  gave  an  accurate  description  of  the 
affection. 

§  2G1.  Etiology. — The  general  causes  of  neuralgia  of  the  fifth 
being  the  same  as  the  general  causes  of  all  forms  of  neuralgia,  they 
need  not  be  recapitulated.  The  female  sex  appears  to  be  more 
susceptible  to  trigeminal  neuralgia  than  to  any  other  superficial 
form  of  the  disease,  except  mammary  neuralgia.  It  also  occurs 
more  frequently  than  any  other  form  of  neuralgia  iu  epileptic 
families.  Anaemia,  arterial  degeneration,  wounds,  cicatrices,  and 
diseases  of  neighbouring  tissues,  exercise  the  same  influence  in 
neuralgia  of  the  fifth  as  in  the  neuralgias  of  other  nerve  territories. 
The  passage  of  this  nerve  through  bony  canals,  however,  renders 
it  very  liable  to  be  implicated  in  various  affections  of  the  bones 
and  periosteum.  Aneurism  of  the  internal  carotid  has  been 
known  to  cause  intractable  neuralgia  by  pressure  on  the  Gasserian 
ganglion.  The  Gasserian  ganglion  has  been  found  almost 
divided  into  two  by  an  exostosis  of  the  petrous  portion  of  the 
temporal  bone  which  had  penetrated  into  it,^  and  the  patient 
suffered  during  life  from  intense  neuralgia  of  the  same  side  of 
the  face.  Tumours  which  compress  the  nerve  at  the  base  of  the 
skull  also  cause  intractable  neuralgia.  The  important  special 
causes  of  facial  neuralgia  are  peripheral  irritations,  as  carious 
teeth,^  retarded  appearance  and  false  development  of  the  wisdom 
teeth,  disease  of  the  nasal  and  frontal  sinuses,  and  over-exertion 
of  the  eyes,  the  last  of  which  was  regarded  by  Dr.  Anstie*  as  the 
most  fruitful  cause  of  trigeminal  neuralgia. 

Neuralgia  of  the  fifth  may  also  be  caused  by  injury  of  remote 
nerves.     Dr.  Anstie^  observed  one  case  in  which  injury  to  the 

1  Fothergill.  "Of  a  painful  affection  of  the  face."  Collected  Works  by  J.  C. 
Lettsom,  1784,  p.  329.  And,  Medical  Observations  and  Inquiries.  VoL  V.,  1773, 
p.  192. 

'^  Chouppe  (H.).  "Petite  exostose  du  rocher  dissociant  les  fibres  du  ganglion  de 
Gasser  et  accompagnee  de  n^vralgie  faciale."  Arch,  de  Physiol.,  Tome  IV.,  1872, 
p.  658. 

^  Cartwright  (H.).  "The  means  of  diagnosis  afforded  by  an  examination  of  the 
teeth  and  mouth  in  doubtful  cases  of  constitutional  disease."  The  British  Medical 
Journal,  Vo).  I.,  1880,  p.  481. 

*  Anstie  (F.  E.).  Neuralgia,  and  the  diseases  that  resemble  it.  Lend.,  1871. 
p.  133. 

*Anstie  (F.  E.V  "On  cejtain  painful  affections  of  the  fifth  nerve."  The 
Lancet,  Vol.  II.,  1866,  p.  32. 


DISEASES   OF  THE  MIXED  CRANIAL  NERVES.  497 

occipital  and  another  to  the  ulnar  nerve  seemed  to  have  caused 
neuralgia  of  the  fifth.  Intestinal  worms,  and  various  genital 
irritations  in  both  sexes,  uterine  disease,^  excessive  mental  strain, 
and  especially  severe  emotional  disturbances,  may  be  mentioned 
as  amongst  the  most  important  of  the  indirect  exciting  causes  of 
trigeminal  neuralgia.  The  first  branch  of  the  fifth  nerve  is  more 
liable  than  any  other  nerve  to  malarial  neuralgia. 

§  262.  SyTnptoms. — Facial  neuralgia,  like  other  forms  of  the 
aflfection,  consists  of  attacks  of  pain  in  the  area  of  distribution  of 
the  nerve  or  one  of  its  branches,  which  manifest  a  tendency  to  a 
periodical  recurrence  on  the  slightest  exposure  to  the  exciting 
cause,  or  even  in  the  absence  of  such  cause.  Each  attack  is 
made  up  of  recurring  paroxysms  of  severest  pain,  separated  by 
intervals  of  comparative  but  not  entire  freedom  from  pain.  The 
actual  outburst  of  severe  pain  may  be  preceded  by  obscure  feel- 
ings of  discomfort,  itching,  or  formication  in  the  side  of  the  face, 
or  by  a  feeling  of  general  malaise,  shivering  and  flying  pains 
about  the  teeth ;  at  other  times  a  severe  dart  of  pain  shoots 
along  the  course  of  one  of  the  branches  of  the  nerve  without 
being  preceded  by  any  warning. 

Each  paroxysm  consists  of  a  succession  of  quick,  lightning-like 
darts  of  pain,  which  emanate  from  one  or  two  foci,  and  radiate 
towards  the  periphery ;  at  first  one  or  two  of  these  flashes  is 
followed  by  a  comparatively  free  interval,  but  they  recur  with 
increasing  severity  and  quickness,  until  they  at  last  blend  into  an 
uninterrupted  pain  of  great  intensity,  during  the  continuance  of 
which  the  patient  suffers  indescribable  agony.^  After  one  or  two 
minutes  the  intensity  of  the  shooting  pains  abates,  but  the 
patient  continues  to  suffer  during  the  interval  from  a  dull  aching 
pain  which  occasions  great  discomfort  and  prevents  sleep.  The 
character  of  the  pain  during  the  paroxysm  varies;  it  may  be 
burning,  boring,  cutting,  crushing,  or  stabbing,  although  the 
lightning-like  shocks  are  most  frequently  met  with.  The  intensity 
and  duration  of  the  disease  may  vary  from  a  slight  attack  which 
never  returns,  consisting  of  a  few  darts  of  pain  or  a  little  tingling 

*  Hoist  (Von).  "Neuralgic  des  Trigeminus,  geheilt  durch  Amputation  der 
Vaginal-portion."    Neurologische  Centralbl.,  1882,  p.  94. 

^  Anstie  (F.  E.).  Neuralgia,  and  the  diseases  that  resemble  it.  London,  1871. 
p.  11. 

VOL.  L  GG 


^8  DISEASES  OF  THE  MIXED   CRANIAL  NERVES. 

of  the  face,  up  to  a  disease  of  the  most  obstinate  character,  that 
recurs  repeatedly  and  with  great  severity  during  the  whole  of 
life,  and  in  which  an  attack  may  be  determined  by  such  a  slight 
exciting  cause  as  a  current  of  cold  air  on  the  cheek,  or  such 
actions  as  chewing,  coughing,  or  washing  the  face. 

In  cases  of  great  severity  the  slightest  external  injury,  as  a 
draught  of  cold  air,  washing  or  shaving  the  face,  sneezing,  or  any 
slight  emotional  disturbance,  may  induce  a  paroxysm  of  the 
disease. 

Painful  points  are  observed  during  the  attacks,  and  some- 
times even  in  the  periods  of  intermission,  corresponding  gene- 
rally to  the  localities  where  the  nerve  becomes  more  superficial, 
either  in  issuing  from  a  bony  canal,  or  in  penetrating  fascise. 

The  concomitant  symptoms  of  trigeminal  neuralgia  are  more 
numerous  and  varied  than  those  of  any  other  form  of  the  disease. 
Irradiation  of  the  pain  to  other  nerve  territories  usually  accom- 
panies a  severe  paroxysm.  When  one  branch  of  the  fifth  is 
affected,  the  pain  extends  during  the  paroxysm  to  the  other 
branches  of  the  same  nerve,  or  to  the  occipital  nerves,  and  it 
may  extend  in  severe  cases  to  the  neck,  shoulders,  or  any  part  of 
the  area  of  distribution  of  the  intercostal  nerves,  especially  the 
mammary  gland.  In  some  cases  it  may  even  extend  to  the 
extremities. 

Either  hypercesthesia  or  ancesthesia  of  the  skin  of  the  affected 
part  is  almost  always  present,  the  rule  being,  although  it  is  not 
without  exceptions,  that  hypersesthesia  is  observed  in  recent, 
and  anaesthesia  in  chronic  cases. 

Disturbances  of  the  organs  of  special  sense  have  in  some 
rare  instances  been  observed.  Photopsia,  amblyopia,  and  even 
amaurosis,  along  with  certain  disorders  in  the  sense  of  hearing, 
have  been  described  by  some  authors  as  the  result  of  facial 
neuralgia.  Affections  of  the  gustatory  and  olfactory  nerves 
are  also  occasionally  mentioned. 

Motor  Disturbances. — Spasm  of  various  muscles  is  the  most 
usual  concomitant  motor  phenomenon,  and  the  muscles  supplied 
by  the  facial  nerve  suffer  most.  The  contraction  of  the  facial 
muscles  sometimes  appears  in  the  form  of  blepharospasm,  some- 
times as  a  contraction  of  the  muscles  at  the  angle  of  the  mouth, 
or  as  true  convulsive  tic.     Both  tonic  and  clonic  spasms  of  the 


DISEASES   OF  THE  MIXED  CEANIAL   NERVES.  499 

muscles  of  mastication  have  been  observed,  but  these  cases  are 
rare,  and  paralysis  of  the  muscles  is  still  rarer.  Spasmodic  move- 
ments of  the  tongue  have  been  observed  in  some  severe  paroxysms. 
These  spasms  may  extend  to  the  muscles  of  the  whole  body,  and 
in  hysterical  subjects  a  neuralgic  paroxysm  may  be  the  starting 
point  of  general  convulsions.  Paralysis  of  some  of  the  ocular 
muscles  has  been  described  in  connection  with  facial  neuralgia, 
but  it  would  probably  be  found  that  such  cases,  if  carefully  inves- 
tigated, had  been  caused  either  by  the  pressure  of  an  intracranial 
tumour  over  the  cavernous  sinus,  or  by  a  lesion  in  the  pons. 

Vaso-viotor  disturbances  are  of  common  occurrence.  In  the 
first  stage  of  the  attack  the  affected  side  of  the  face  is  unusually 
pale,  but  subsequently  the  pallor  is  replaced  by  intense  redness, 
and  the  skin  then  becomes  glossy  and  presents  a  slight  cede- 
matous  swelling.  The  redness  extends  to  the  mucous  membranes 
supplied  by  the  affected  nerve,  and  the  conjunctiva  is  specially 
affected  and  presents  a  high  degree  of  hypersemia.  Visible 
perspiration  and  strong  pulsation  of  the  carotid,  facial,  and 
temporal  arteries  of  the  affected  side  of  the  face  may  also  be 
observed  during  the  attack. 

Secretory  disturbances  are,  as  might  have  been  anticipated, 
also  common,  and  increase  of  the  lachrymal  secretion  is  by  far 
the  most  frequent  of  these.  Both  the  lachrymal  and  orbital 
nerves  are  known  to  contain  secretory  fibres  for  the  lachrymal 
gland,  and  irritation  of  the  sensory  branches  of  the  first  and 
second  divisions  of  the  fifth  nerve  increases  the  flow  of  tears 
by  reflex  action.  Augmented  salivary  secretion  is  sometimes 
present,  and  the  secretion  of  the  nasal  mucous  membrane  of  the 
affected  side  may  either  be  arrested  or  increased. 

Tro]phic  disturbances  of  various  forms  are  met  with  in  con- 
nection with  trigeminal  neuralgia.  The  most  usual  of  these  are 
swelling  of  the  face,  changes  in  the  colour  and  texture  of  the 
hair,  herpes  zoster  frontalis,  erysipelas,  subacute  inflammation  of 
the  periosteum  and  of  the  fibrous  membranes  in  the  neighbour- 
hood of  the  painful  points,  neuroparalytic  ophthalmia,  iritis,  and 
glaucoma.^  In  aggravated  and  long-continued  cases  the  incessant 

'  See  Anstie  (F.  E.).  Op.  cit.,  pp.  98  and  102.  The  Lancet,  "On  painful  affec- 
tions of  the  fifth  nerve,"  Vol.  II.,  1866,  p.  200.  And  Notta  (A.).  "M^moire  sur 
lea  lesions  fonctionnelles  qui  Bont  sous  la  d^pendance  des  nevralgies."  Arch.  gen6r. 
de  M6d.,  V^  S^rie,  Tome  IV.,  Vol.  II.,  1854,  pp.  1  and  290. 


500 


DISEASES  OF  THE  MIXED  CKANIAL  NERVES. 


pain  and  its  attendant  sleeplessness  undermines  the  constitution, 
the  general  nutrition  becomes  impaired,  and  at  last  the  patient 
suffers  from  marasmus  and  nervous  exhaustion. 

The  'psychical  disturbances  present  are  mental  irritability 
and  despondency,  hysterical  seizures,  and  occasionally  patients 
have  committed  suicide  in  order  to  escape  from  their  sufferings. 

VARIETIES  OF  TRIGEMINAL  NEURALGIA. 

§  263.  Neuralgia  of  the  First  Branch  of  the  Fifth  (Oph- 
thalmic Neuralgia). — The  several  branches  of  the  ophthalmic 
division  of  the  fifth  nerve  may  either  all  be  affected  or  the 
neuralgia  may  be  limited  to  some  particular  branch.  The 
painful  points  in  connection  with  the  ophthalmic  division  of  the 
nerve  are  -} 

Fig.  51. 


Fig.  51  (after  Flower). 
First  division  of  the  fifth : 

SO,  Supra  orbital. 

ST,  Supra  trochlear. 

IT,  Infra  trochlear. 

L,  Lachr3rmal. 

N,  Nasal. 
Second  division  of  the  fifth : 

10,  Infra  orbital. 

TM,  Temporo  malar. 


Sensory  Nerves  of  the  Head  and  Face. 
Third  division  of  the  fifth  : 
B,  Buccal. 
M,  Mental 

AT,  Auriculo  temporal. 
Branches  of  the  cervical  plexus 
GO,  Great  occipital. 
S'O',  Small  occipital. 
GA,  Great  auricular. 
SO,  Superficial  cervicaL 
IIIC,  Third  cervical. 


1  See  Valleix.    Traits  de  n^vralgies  ou  affections  doioloureuses  des  nerfs.    Pane, 
1841. 


DISEASES  OF  THE  MIXED   CRANIAL  NERVES.  501 

(1)  The  supra-orhital  at  the  supra-orbital  foramen,  or  a  little  higher, 
iu  the  coui-se  of  the  frontal  nerve  ;  (2)  ih.e palpebral,  in  the  upper  eyelid  ; 
(3)  the  nasal,  at  the  point  of  emergence  of  the  long  nasal  branch,  at  the 
junction  of  the  nasal  bone  with  the  cartilage ;  (4)  the  ocular,  a  somewhat 
indefinite  focus  within  the  globe  of  the  eye,  when  the  ciliary  nerves  are 
affected  ;  (5)  the  trochlear,  at  the  inner  angle  of  the  orbit. 

Supra-orbital  neuralgia  is  the  form  which  generally  results 
from  exposure  to  cold;  it  is  also  almost  the  exclusive  seat  of 
malarial  neuralgia.  The  characteristic  features  of  this  form  of 
the  affection  are  pain  in  the  forehead,  extending  downwards  to 
the  upper  eyelid  and  root  of  the  nose,  hypersemia  of  the  conjunc- 
tiva, lachrymation,  and  in  nearly  all  cases  a  well-jnarked  painful 
spot  at  the  supra-orbital  foramen.  The  attacks  of  malarial  neu- 
ralgia recur  with  great  regularity ;  each  begins,  as  a  rule,  at  a 
fixed  hour  in  the  morning,  and  continues  for  two  or  three  or 
more  hours,  and  the  pain  is  described  as  being  very  intense. 
Seeligmiiller^  believes  that  this  form  of  neuralgia  is  caused  by  a 
catarrhal  affection  of  the  frontal  sinuses.  Upon  this  view  he  has 
based  a  new  method  of  treatment,  which  will  be  immediately 
described. 

/ 

§  264.  Neuralgia  of  the  Second  Division  of  the  Fifth  Nerve 
{Supra-maxillary  Neuralgia). — When  all  the  branches  of  the 
nerve  are  affected  the  pain  is  situated  in  the  cheek,  eyelid> 
lateral  portion  of  the  nose  and  upper  lip  (infra-orbital  nerve), 
in  the  zygomatic  arch  and  anterior  temporal  region  (orbital 
nerve),  in  the  upper  row  of  teeth  (dental  branches),  and  in  the 
nasal  cavities  and  gums  (naso -palatine  and  posterior  palatine 
nerves). 

Infra-orbital  neuralgia  is  the  most  common  variety  affecting 
the  second  division  of  the  nerve,  and  it  is  also  the  severest  of  all 
the  forms  of  facial  neuralgia  which  are  limited  to  one  branch  of 
the  fifth  nerve.  The  characteristic  pain  is  localised  in  the  cheek, 
upper  lip,  upper  row  of  teeth,  and  neighbourhood  of  the  zygo- 
matic arch.  A  form  of  neuralgia  has  been  described  by  Gross,^ 
which  appears  to  have  its  seat  in  the  remnants  of  the  alveolar 

1  Seeligmiiller  (A.).  "  Neuralgia  supra-orbitalia  intermittens."  Centralbl.  f. 
Nervenheilkunde,  Bd.  III.,  1880,  p.  209. 

"  Gross  (S.  D.).  "^Form  of  neuralgia  of  the  jaw-bones,  hitherto  undescribed." 
The  American  Journal  of  the  Medical  Sciences,  Vol.  LX.,  1870,  p.  48. 


502 


DISEASES  OF  THE  MIXED  CRANIAL   NERVES. 


processes,  or  the  overlying  gum  in  elderly  persons  who  have  lost 
their  teeth,  the  upper  being  more  frequently  affected  than  the 
lower  jaw.     The  character  of  the  pain  varies;  it  is  sometimes 


Fig.  52. 


"Fig.  52    (from    Hermann's    "Physiology").     Diagram    of   the   Second   (Superior 
Maxillary)  Division  of  the  Fifth  Nerve,  its  connections  and  chief  branches. 

V,  Placed  over  Gasserian  ganglion. 

a,  rirst  or  ophthalmic  division,  with  d  its  frontal,   e  its  lachrymal,   and  /  its 
nasal  branches. 

b,  Second  or  superior  maxillary  division,   branches  of  which  are  marked  as 
follows  :  — 

1,  Its  terminal  branches,  nasal,  labial,  and  palpebral. 

2,  Recurrent  branch  to  the  dwa  mater,  and  middle  meningeal  artery. 

3,  Orbital  branch. 

4  is  placed  between  the  two  spheno-palatine  branches  (which  descend  to 
Meckel's  ganglion). 

5,  Dental  branches. 
MGr,  Meckel's  ganglion. 

6,  The  Vidian  nerve  (constituting  the  motor    and    sympathetic   root    of 

Meckel's  ganglion). 

7,  The  great  superficial  petrosal  nerve, -"from  the  geniculate  ganglion  of  the 

facial  nerve,  joining  the  Vidian. 

8,  The  sympathetic  branch  from  the  plexus  on  the  carotid  artery,  joining  the 

great  superficial  petrosal,  and  forming  with  it  the  Vidian  nej've. 

9,  Ascending  branches  of  Meckel's  gangUon. 

10,  Descending  palatine  branches. 

11,  Naso-palatine  branch. 

12,  Upper  nasal  branches. 

13,  Pharyngeal  branch. 

E,  Facial  nerve.      CA,  Carotid  artery.      IF,  Infra-orbital  foramen. 


DISEASES   OF   THE  MIXED   CEANIAL  NERVES. 


503 


sharp  and  darting  and  at  other  times  dull  and  aching,  boring,  or 
gnawing.   It  often  comes  and  goes  with  the  rapidity  of  lightning, 


Fig.  53. 


Flu.  53  (from  Hermann's  "Physiology").    Diagram  of  the  Third  (Inferior  Maxillary) 

Division  of  the  Fifth  Nervt,  its  connections  and  chief  branches. 
V,  Fifth  nerve.     6,  Its  largest  sensory  root,  with  the  Gasserian  ganglion. 

a,  Its  smaller  motor  root  joining  e,  the  third  divLsion  of  the  Gasserian  ganglion, 
to  form  the  inferior  maxillary  nerve. 

A,  Anterior  division  of  inferior  maxillary  nerve  (mainly  motor)   supplying 

branches  to  the  muscles  of  mastication,  and  a  terminal  buccal  branch  to 
the  miicous  membrane  of  the  mouth. 

B,  Posterior  division  (mainly  sensory) ;  its  branches  are  marked — 

1,  Lingual  nerve;  1',  Branches  to  the  tongue. 

2,  Inferior  dental  nerve ;  2',  Its  twigs  to  the  teeth ;  2",  Incisor  branch ; 

2'",  Mental  branch. 

3,  Mylo-hyoid  branch  to  digastric  and  mylo-hyoid. 

4,  Auriculo-temporal  nerve. 

F,  Facial  nerve,    ct.  Its  chorda  tyrnpani  branch,  joining  the  lingual,  and  running 
to  the  submaxillary  ganglion  SG,  of  which  it  forms  the  motor  root. 
OG,  Otic  ganglion: 
ssp,  Small  superficial  petrosal  nerve,  connecting  otic  ganglion  and  facial  nerve. 
M,  Middle  meningeal  artery,  from  the  plexus  upon  which  sympathetic  filaments 
pass  to  the  otic  ganglion  ; 
es}},  External  superficial  ptetrosal  nerve,  connecting  the  plexus  on  the  middle 

meningeal  artery  with  the  facial  nerve  ; 
gsp,    Great   superficial  petrosal   nerve,    connecting  the  facial  with  Meckel's 
ganglion. 
FA,  Facial  artery,  from  the  plexus  upon  which  sympathetic  filaments 

pass  to  the  submaxillary  ganglion. 
FO,  Foramen  ovale.  MF,  Mental  foramen. 

SG.  Submaxillary  ganglion. 


504)  DISEASES  OF  THE  MIXED   CRANIAL  NERVES. 

but  occasionally  lasts  for  hours  together.  He  has  found  the  bone 
at  the  seat  of  the  disease  always  unduly  hard,  apparently  from 
the  deposit  of  new  substance,  and  he  believes  that  the  osseous 
changes  are  such  as  to  cause  compression  of  the  small  branches 
of  the  nerve  as  they  pass  through  bony  canals  to  their  terminal 
distribution. 

The  painful  points  in  supra-maxillary  neuralgia  are:  (1)  The  infra- 
orbital, corresponding  to  the  emergence  of  the  nerve  of  that  name  from  its 
bony  canal ;  (2)  the  malar,  on  the  most  prominent  part  of  the  malar  bone ; 
(3)  a  vague  and  indeterminate  focus  somewhere  on  the  hne  of  the  gum  of 
the  upper  jaw ;  (4)  the  superior  labial,  also  vague  and  unimportant ;  (5)  the 
palatine  point,  rarely  observed,  but  occasionally  the  seat  of  intolerable  pain. 
« 

§  265.  Neuralgia  of  the  Third  Division  of  the  Fifth  Nerve 
(Infra-maxillary  Neuralgia). — When  all  the  branches  of  this 
division  of  the  nerve  are  affected,  pain  occurs  in  the  region  of 
the  lower  jaw  and  lower  row  of  teeth  (inferior  dental  nerve),  in 
the  chin  (mental  branch),  in  the  tongue  and  mucous  membrane 
of  the  mouth  (lingual  nerve),  in  the  cheek  (buccal  nerve),  and  in 
the  temporal  region,  anterior  part  of  the  auricle  of  the  ear,  and 
external  auditory  meatus  (auriculo-temporal  nerve). 

The  painful  points  are:  (1)  The  temporal,  a  point  on  the  am-iculo- 
temporal  branch,  a  Httle  in  front  of  the  ear  ;  (2)  the  inferior  dental  point, 
opposite  the  point  of  emergence  of  the  nerve  of  that  name  ;  (3)  the  lingual 
point  on  the  side  of  the  tongue,  but  it  is  rarely  met  with ;  (4)  the  inferior 
labial  point,  also  rarely  observed.  Besides  the  painful  points  which  are  in 
relation  with  distinct  branches  of  the  trigeminus,  there  is  a  point  situated 
a  little  above  the  parietal  eminence  which  is  more  commonly  affected  in 
facial  neuralgia  than  any  other  point.  The  parietal  point  corresponds  to 
the  inosculation  of  various  branches  of  the  nerve. 

The  cases  of  facial  neuralgia  which  have  been  described  by 
Trousseau^  under  the  name  of  "Epileptiform  Neuralgia,"  are 
extremely  severe  and  obstinate.  Pains  of  the  most  violent  and 
lightning-like  nature  succeed  each  other  with  the  greatest 
rapidity  for  a  few  seconds  or  minutes,  and  then  suddenly  vanish. 
But  these  short  attacks  may  recur  and  follow  each  other  in 
quick  succession  for  a  period  of  hours,  days,  or  even  weeks ;  then 
follows  a  respite,  and  the  paroxysm  disappears  for  days,  weeks, 

I  Trousseau  (Prof.  A.).  "De  la  n^vralgie  ^pileptiforme."  Arch,  g^n^ral  de 
m^d.,  Ve  S^rie,  Tome  I,  1853,  Vol.  I.,  p.  33. 


DISEASES   OF  THE   MIXED   CRANIAL  NERVES.  505 

or  even  years,  although  relapses  are  sure  to  take  place  after  a 
longer  or  shorter  time.  This  form  of  neuralgia  is  of  centric 
origin;  it  occurs  in  families,  manifesting  a  proclivity  to  psychoses, 
and  is  frequently  accompanied  by  epilepsy ;  or  it  is  associated 
with  a  high  degree  of  excitability  and  with  strongly-marked 
mental  activity.  The  prognosis  of  this  form  of  neuralgia  is  un- 
favourable, although  not  so  grave  as  Trousseau  believed  it  to  be. 

§  266.  Course,  Duration,  and  Terminations. — The  slighter 
forms  of  facial  neuralgia  may  last  a  few  hours  only,  but  the 
severer  forms  of  tic  douloureux  continue  to  affect  the  patient  for 
the  remainder  of  his  life.  The  great  majority  of  cases  terminate 
in  recovery,  the  most  favourable  being  those  which  arise  from 
malaria,  exposure  to  cold,  rheumatism,  or  anaemia.  The  most 
unfavourable  cases  are  those  in  which  there  is  a  well-marked 
hereditary  predisposition,  especially  if  the  patient,  or  some  mem- 
bers of  his  family,  be  epileptics,  and  those  which  come  on  at  a 
late  period  of  life,  and  are  associated  with  arterial  degeneration. 
The  disease  is  incurable  when  it  is  caused  by  severe  organic 
affections,  and  also  in  some  of  the  cases  which  Trousseau  has 
called  epileptiform  neuralgia. 

§  267.  Diagnosis. — Facial  neuralgia  may  be  confounded  with 
toothache,  but  in  the  latter  the  pain  is  continuous,  and  one  or 
more  of  the  teeth  will  be  found  carious,  and  sensitive  to  cold  and 
mechanical  shock.  It  may  also  be  mistaken  for  inflammation  of 
the  facial  bones,  and  of  the  membranes  lining  the  antrum  and 
frontal  sinuses,  but  in  these  cases  there  must  be  some  degree  of 
tumefaction  and  general  tenderness  to  pressure,  while  the  situa- 
tion and  kind  of  pain  do  not  correspond  to  that  of  any  of  the 
branches  of  the  fifth  nerve.  Hysterical  clavus  is  distinguished 
from  neuralgia  by  being  limited  to  one  spot  from  which  the 
pain  does  not  radiate,  and  by  the  presence  of  other  hysterical 
symptoms. 

In  angemic  or  dyspeptic  headache,  the  pain  has  no  fixed 
position,  it  is  deep-seated,  dull,  tensive,  and  does  not  increase  in 
paroxysms ;  in  migraine  the  pain  is  deeply  seated  in  the  skull, 
pulsating,  accompanied  by  vomiting  and  much  mental  irritability, 
and  does  not  correspond  with  any  special  branch  of  nerve. 


506  DISEASES   OF  THE  MIXED   CRANIAL  NERVES. 

It  is  important  to  distinguish  between  neuralgia  of  peripheral 
and  of  central  origin.  Limitation  of  the  pain  to  a  definite  branch 
of  the  nerve,  the  presence  of  some  manifest  peripheric  cause,  the 
possibility  of  cutting  short  the  attack  by  remedies  applied  to 
the  periphery,  and  the  presence  of  painful  points  in  the  intervals 
between  the  paroxysms,  may  be  taken  as  signs  that  the  disease 
is  of  peripheral  origin.  Lancinating  pains,  localisation  in  bones, 
widely  distributed  reflex  contractions,  general  hypersesthesia,  well- 
marked  mental  irritability,  disorders  of  other  cerebral  nerves,  and 
absence  of  painful  points  in  the  intervals  between  the  attacks, 
may  be  taken  as  indications  of  the  central  origin  of  the  disease. 

§  268.  Treatment. — The  treatment  of  facial  neuralgia  must 
be  conducted  on  the  broad  principles  already  described,  while 
treating  of  the  subject  of  general  neuralgia,  and  it  is  only 
necessary  at  present  to  mention  a  few  special  points  with  respect 
to  the  treatment  of  individual  cases.  In  cases  of  supra-orbital 
neuralgia  of  malarial  origin,  large  doses  of  quinine  constitute  the 
most  effectual  remedy,  and  often  do  good  in  other  cases.  One 
large  dose  of  a  scruple  may  be  administered,  or  four  grains  may 
be  given  every  four  hours  until  the  pain  is  relieved,  or  until 
headache  and  noises  in  the  ears  render  it  necessary  to  desist. 

If  the  neuralgia  be  caused  by  osteitis,  periostitis,  or  neuritis 
from  any  other  cause,  an  energetic  antiphlogistic  treatment  must 
be  adopted ;  in  rheumatic  cases  diaphoresis  and  the  internal 
administration  of  colchicum  and  opium,  or  salicylate  of  soda 
should  be,  employed.  Every  source  of  peripheral  irritation  should 
be  removed.  Amongst  the  most  usual  of  these  are  carious  teeth, 
foreign  bodies  pressing  upon  and  injuring  the  nerves,  cicatrices, 
tumours,  land  neuromata,  and  the  removal  of  these  often  leads 
to  speeds  recovery.  Great  attention  should  be  paid  to  the 
general  Ifiealth,  more  especially  if  anaemia  or  hereditary  pre- 
disposition be  present. 

The  constant  current  has  been  found  very  successful  in  the 
treatment  of  obstinate  neuralgias.  In  peripheral  neuralgia  of 
isolated  superficial  nerves  the  direction  method  may  be  employed, 
and  a  descending  stabile  current  passed  through  the  painful  nerve. 
When  the  polar  method  is  used,  the  anode  is  to  be  placed  on  the 
specially  painful  points  and  held  stationary  there,  whilst  the 


DISEASES   OF  THE   MIXED   CRANIAL  NERVES.  507 

cathode  rests  on  the  back  of  the  neck,  or  on  any  other  in- 
different part  of  the  body.  When  the  deeper-seated  nerves,  as 
the  infra-orbital  and  lingual,  are  affected,  the  anode  may  be 
placed  on  the  neck  or  behind  the  ear,  and  the  cathode 
over  the  point  of  emergence  of  the  affected  nerve.  In  order  to 
reach  the  main  divisions  of  the  nerve  at  the  base  of  the  cranium, 
and  after  their  emergence  through  the  foramina  of  the  sphenoid 
bone,  the  current  may  be  conducted  transversely  through  the 
base  of  the  skull  at  the  appropriate  spots,  the  anode  being  placed 
on  the  painful  side.  Benedict  recommends  that  in  severe  cases 
galvanic  currents  should  be  passed  longitudinally  and  transversely 
through  the  skull,  and  along  the  sympathetic  nerve.  Faradisation 
occasionally  answers  better  than  the  constant  current.  The  moist 
poles  should  be  employed  and  applied  to  the  painful  points  and 
along  the  nerve  trunks. 

Narcotics,  and  more  especially  subcutaneous  injections  of 
morphia,  are  useful  in  this  as  in  all  other  forms  of  neuralgia.  It 
may  be  advantageous  to  change  sometimes  from  morphia  to 
strammonium,  hyoscyamus,  or  belladonna,  and  each  must  be 
given  in  increasing  doses. 

Trousseau^  advised  the  use  of  large  doses  of  opium  or  morphia 
in  the  treatment  of  epileptiform  neuralgia.  In  some  cases  he 
gave  as  much  as  a  drachm  of  morphia,  or  two  or  three  of  opium 
in  the  course  of  the  day,  a  treatment  which  is  occasionally  suc- 
cessful, but  must  be  used  with  caution,  and  only  resorted  to 
when  all  other  methods  have  failed.  Ointments,  containing 
opium,  veratria,  aconitia,  or  equal  parts  of  chloral  hydrate  and 
camphor,  may  be  rubbed  into  the  skin  over  the  painful  nerve, 
and  chloroform,  both  as  an  external  application  and  by  inhalation, 
has  been  found  useful. 

Quinine,  arsenic,  zinc,  nitrate  of  silver,  chloride  of  gold  and 
sodium,  strychnia,  carbonate  of  iron,  and  iodide  of  potassium  are 
the  most  useful  internal  remedies  ;  of  these  arsenic  is  by  far  the 
most  generally  useful,  except  in  neuralgia  of  malarial  or  syphilitic 
origin,  in  which  case  quinine  or  iodide  of  potassium  must  be  given 
according  to  the  nature  of  the  case.  In  malarial  neuralgia 
Seeligmiiller  recommends  the  use  of  the  nasal  douche  an  hour 
before  the  expected  attack  in  the  morning,  and  at  night  before 

'  Trousseau.    Loc.  cit,  p.  113. 


508  DISEASES   OF   TflE  MIXED   CRANIAL   NERVES. 

/ 

)ing  to  bed.  He  advises  about  a  pint  of  warm  water  or  milk 
ho  be  used  at  first,  and  a  weak  solution  of  common  salt  at  a  later 
period  of  tiio  disease,  in  obstinate  cases  he  lias  employed  a 
solution  of  salicylate  of  soda,  or  a  solution  of  a  quarter  to  baif  per 
cent  of  carbolic  acid.  He  appears  to  bave  bad  great  success  witb 
this  treatment  in  about  a  dozen  cases.  Gelseminum  semper- 
virens,  best  given  in  the  form  of  tincture,  and  croton  chloral 
hydrate,  either  in  one  largo  dose  of  a  scruple  or  four  grains  every 
four  hours,  bave  also  been  found  useful,  but  in  my  experience  they 
are  of  no  use  in  obstinate  cases.  Tonga  is  a  remedy  which  has 
recently  been  introduced  into  this  country  by  Dr.  S.  Ringer^  for 
the  cure  of  neuralgia.  A  drachm  of  a  liquid  extract  prepared  by 
Messrs.  Allen  and  Hanbury  may  be  taken  every  four  hours.  The 
drug  does  not  appear  to  have  any  toxic  action,  and  much  larger 
doses  may  be  given  with  impunity.  When  there  is  anajmia,  car- 
bonate of  iron  may  bo  given  along  witli  cod-liver  oil. 

Various  counter-irritants  bave  been  employed,  but  they  do  not 
appear  to  give  much  relief,  and  as  they  cause  considerable  pain 
they  shoidd  not  be  needlessly  employed.  Patients  often  expe- 
rience great  relief  from  warm  fomentations  and  poultices,  but  can 
rarely  bear  the  application  of  cold.  In  severe  cases  I  have  seen  the 
constant  application  of  an  ice  bag  of  temporary  use.  Continuous 
pressure  may  be  tried  on  the  nerve  at  the  painful  points. 

Sea-water  bathing,  thermal  vapour  baths,  and  "  cold  water 
cures"  are  often  followed  by  favourable  results.  In  intractable 
cases,  when  all  other  methods  have  failed,  recourse  must  be  had 
to  neurotomy  or  neurectomy  ;  in  many  cases  immediate  relief 
is  afforded,^  but  frequently  the  pains  return  in  from  three 
to  twelve  months,^  and  the  operation  has  to  be  repeated.  In 
some  cases  not  even  temporary  relief  is  afforded  by  the  opera- 
tion.* Nerve  stretching,  however,  affords  a  much  safer  and 
probably  equally  effectuaj  method  of  treatment.^    In  the  form  of 

'  Ringer  (.S.).  "  On  Tonga  :  A  remedy  for  neuralgia,  used  by  the  natives  of  the 
Fiji  iHlandH."    The  Lancet,  Vol.  I.,  1880,  p.  300. 

''■  See  Jiraun  (H.).  "  Neurectomieen  dew  zweiton  AstcB  des  N.  trigeminus  nach 
OBteoplaHt.  Jiesoction  doH  Jochbeina."    Neurologische  Centralbl.,  1882,  p.  356. 

"  Cadge  (W.).  "Nerve  section  in  the  treatment  of  neuralgia."  British  Medical 
Journal,  Vol.  II.,  1882,  p.  83. 

"  Aronheim.     Centralbl.  f.  nervenh.    Bd.  IV.,  1881,  p.  322. 
"  Underwood   (A.   S.).       "  Nerve-stretching  in  neuralgia."      British  Medical 
Journal,  Vol.  I.,  1880,  p.  851. 


DISEASES  OF  THE  MIXED   CRANIAL  NERVES.  509 

alveolar  neuralgia,  described  by  Gross,  the  affected  portion  of 
bone  must  be  removed  by  cutting  pliers  and  gouge. 

(4)— TROPHIC    AFFECTIONS    IN   THE    TERRITORY   OF   THE 
TRIGEMINUS. 

Herpes  zoster^  is  frequently  found  in  the  area  of  distribution 
of  single  branches  of  the  trigeminus  (§  115).  The  eruption  is 
generally  unilateral,  although  in  some  cases  it  has  been  observed 
on  both  sides  of  the  face.  In  the  latter  cases  the  disease  was  dis- 
tributed over  all  the  branches  of  the  trigeminus.  Neuralgia  may 
or  may  not  be  associated  with  herpes.  Herpes  in  the  region  of 
the  frontal  nerve  is  often  a  very  severe  affection,  being  ushered 
in  by  hemicrania,  general  headache,  or  frontal  neuralgia.  When 
descending  branches  of  the  nerve  are  affected,  the  eruption  ex- 
tends over  the  upper  eyelid  and  the  side  of  the  nose,  and  the 
conjunctiva  becomes  implicated.  In  severe  eases  the  eyeball 
becomes  affected,  giving  rise  to  inflammation,  not  only  of  the 
conjunctiva,  but  of  the  cornea,  and  even  general  inflammation  of 
the  eyeball  may  result,  the  most  prominent  feature  being  iritis. 
That  these  inflammatory  conditions  depend  upon  irritation  of 
the  trigeminus,  and  of  the  Gasserian  ganglion,  has  been  proved 
by  the  post-mortem  examinations  of  Wyss  and  Kaposi,  who 
found  evidence  of  neuritis  and  hgeraorrhage  in  the  ganglion. 
Gerhardt  thinks  that  the  herpes  labialis,  which  is  so  frequently 
present  in  acute  diseases,  such  as  pneumonia,  is  due  to  irritation 
of  single  branches  of  the  trigeminus,  caused  by  sudden  dilatation 
of  arteries  in  the  narrow  bony  canals  through  which  the  branches 
of  the  nerve  pass. 

§  269.  Simple  Glaucoma. — Bonders  in  1862  directed  atten- 
tion to  the  fact  that  simple  glaucoma  appeared  to  be  due  to 
irritation  inf  the  secretory  fibres  which  are  conveyed  in  the  tri- 
geminus. It  is  maintained  by  Wegner,  however,  that  the 
intraocular  increase  of  pressure,  on  which  glaucoma  depends,  is 
caused  by  irritation  of  the  cervical  sympathetic,  in  which  the 
vaso-motor  nerves  are  conveyed.     He  thinks  that  increase  of 

'Hutchinson  (J.).  "A  clinical  report  on  herpes  zoster  frontalis  sur  ophthal- 
micus." Royal  London  Ophthalmic  Hospital  Reports,  Vol.  V.,  part  3,  1866. 
And  Wyss  (O.).  "  Beitrag  zur  Kenntniss  der  Herpes  Zoster."  Arch.  f.  Heil- 
kunde,  1871. 


510  DISEASES   OF  THE  MIXED   CRANIAL  NERVES. 

the  intraocular  pressure  may  be  caused  in  a  reflex  manner 
by  irritation  of  the  sensory  trigeminus  branches.  The  experi- 
ments of  Hippel  and  Griinhagen  show  that  irritation  of  the 
trigeminus  nucleus  in  the  medulla  oblongata  is  followed  by 
a  considerable  and  enduring  increase  of  the  intraocular  pressure ; 
the  same  result  is  produced  by  the  peripheral  trigeminal  irritation 
caused  by  the  introduction  of  nicotine  into  the  eye.  According  to 
these  experiments,  glaucoma  may  be  produced  either  by  central 
or  peripheral  irritation  of  the  trigeminus.  The  increase  of  the 
intraocular  pressure  is  caused  by  augmented  secretion  of  the 
aqueous  humour.  The  results  of  this  high  tension  are  that  the 
iris  and  lens  are  pushed  forwards,  and  the  internal  membranes 
are  stretched.  The  increase  of  pressure  in  the  globe  of  the  eye 
frequently  observed  in  different  forms  of  trigeminal  neuralgia,^ 
the  previous  occurrence  of  neuralgia  of  the  external  facial 
branches  of  the  trigeminus,  of  ciliary  neuralgia  and  hemicrania 
in  simple  as  well  as  in  inflammatory  glaucoma,  the  return  of  the 
increased  intraocular  pressure  with  every  attack  of  neuralgia, 
are  decidedly  in  favour  of  the  dependence  of  glaucoma  upon 
irritation  of  the  trigeminus.  This  opinion,  however,  is  not 
accepted  by  all  pathologists.^ 

§  270.  Neuro-paralytic  Ophthalmia. — It  was  first  shown  by 
Majendie  that  intracranial  destruction  of  the  trigeminus  in 
rabbits,  especially  below  the  Gasserian  ganglion,  was  followed  by 
a  severe  nutritive  disturbance  of  the  eye  on  the  affected  side. 

The  affectibn  begins  with  strong  congestion  of  the  conjunctival 
vessels,  followed  by  profuse  secretion  of  mucus  or  pus,  insensibility 
and  opacity  m  the  cornea,  and  redness  and  pseudo-membranous 
exudation  of  the  iris.  In  from  five  to  ten  days  ulceration  and 
perforation  of  the  cornea  occurs,  which  is  followed  by  loss  of  the 
humours,  and  collapse  of  the  eye.^ 

Cases  of  this  kind  have  been  observed  in  man  in  connection 
with  complete  or  incomplete  aneesthesia  of  the  trigeminus. 

1  Carter  iR.  B.).  "Lectures  on  questions  in  ophthalmic  surgery."  The  Lancet, 
Vol.  IL,  1876,  p.  111. 

'  Smith  (Priestley).  "  The  pathology  of  glaucoma."  Transactions  of  the  Inter- 
national Medical  Congress,  Vol.  III.,  1881,  p.  84. 

^  See  Galezowsld.  "  Sur  les  affections  oculairea  provenant  de  la  lesion  de  la  5« 
paire."    Recueil  d'ophthalmologie,  1875,  p.  353. 


DISEASES   OF  THE   MIXED   CRANIAL   NERVES.  oil 

Three  suppositions  in  explanation  of  these  phenomena  are  possible  : — 

(1)  That  the  lesion  of  the  eye  results  from  the  fact  that  the  presence  of 
anaesthesia  does  not  enable  it  to  protect  itself  against  external  injury.  (2) 
That  it  is  due  to  paralysis  of  vaso-motor  fibres  contained  in  the  trigeminus. 
(3)  That  it  is  due  to  injury  of  trophic  fibres,  and  is  analagous  to  the  cuta- 
neous trophic  affections  already  described.  The  first  supposition  was  sup- 
ported by  Snellen  and  Biittner,  but  it  is  contradicted  by  the  facts  that,  in 
complete  anaesthesia  of  the  eye,  this  afiection  may  fail  to  appear;  and,  con- 
versely, the  nutritive  afiection  may  appear  in  nexiralgia  or  partial  destruction 
of  the  trigeminus  when  the  conjunctival  sensibility  is  completely  main- 
tained. In  paralytic  lagophthalmos  from  paralysis  of  the  facial,  when  the 
eye  is  in  the  highest  degree  unprotected  from  external  sources  of  irritation, 
the  severe  affection  observed  in  trigeminal  injury  altogether  fails. 

The  vaso-motor  theory  is  rendered  improbable  by  the  facts  that  extir- 
pation of  the  superior  cervical  ganghon  not  only  does  not  cause  ophthalmia, 
but  even  diminishes  the  consequences  which  follow  from  subsequent 
destruction  of  the  trigeminus,  or  improves  the  symptoms  already  caused  by 
a  previous  injury  to  the  fifth  nerve  (Sinitzin). 

The  third  supposition,  attributing  the  ophthalmia  to  an  irritation  of 
trophic  fibres  which  probably  descend  from  the  Gasserian  ganghon,  is  by 
far  the  most  probable. 

The  most  frequent  causes  of  this  affection  in  man  are  intracranial 
tumours  and  tubercular  meningitis,  which  imphcate  the  Gasserian  ganghon 
or  invade  the  origin  of  the  fifth  nerve. 

(5)-M0T0K  DISTURBANCES  EST  THE   REGION  OF  DISTRIBUTION 
OF   THE   TRIGEMINAL    NERVE. 

Masticatory  Spasm.     Trismus. 

Id  masticatory  spasm  the  affection  is  limited  to  the  muscles 
supplied  by  the  motor  division  of  the  fifth  nerve.  The  spasm 
may  be  either  tonic  or  clonic,  and  it  is  as  a  rule  bilateral. 

In  the  tonic  variety  the  lower  jaw  is  approximated  to  the 
upper,  and  in  the  severe  form  of  the  affection  the  teeth  are  so 
powerfully  clenched  that  they  cannot  be  separated  from  one 
another  by  force  ;  this  constitutes-  the  condition  termed  lock-jaw 
or  trismus.  The  muscles  of  the  jaw  are  tense,  rigid,  often 
painful,  and  mastication  is  impossible. 

In  the  clonic  form  the  lower  jaw  is  moved  either  in  a  vertical 
or  horizontal  direction ;  the  former  giving  rise  to  chattering  of  the 
teeth,  as  in  the  cold  stage  of  ague,  and  the  latter  to  grinding  of 
the  teeth  accompanied  by  munching  movements.  The  depressors 
of  the  jaw  are  sometimes  subject  to  spasm,  usually  of  the  tonic 
variety.   Associated  symptoms,  depending  on  the  primary  lesion, 


512  DISEASES  OF  THE  MIXED  CEANIAL  NEEVES. 

are  also  usually  present.  The  most  common  of  these  are  trige- 
minal neuralgia,  toothache,  symptoms  of  periostitis  of  the  lower 
jaw,  and  various  cerebral  symptoms.  The  sequelse  to  masticatory 
spasm  are  such  as  biting  of  the  tongue  and  lips,  ulcerations  and 
inflammation  of  the  gums  and  mucous  membrane  of  the  mouth, 
and  inanition,  consequent  upon  deficient  supply  of  nourishment. 
The  teeth  are  usually  much  worn  in  the  clonic  variety  by  the 
constant  grinding  against  each  other,  and  they  may  even  be 
broken  by  the  violence  of  the  spasm. 

Etiology. — Bilateral  masticatory  spasm  is  often  a  concomitant 
symptom  of  general  spasms,  such  as  tetanus,  epilepsy,  eclampsia, 
hysteria,  and  chorea.  At  other  times  it  occurs  as  a  separate 
symptom.  The  affection  may  then  be  caused  by  diseased  con- 
ditions of  the  nerves  themselves,  such  as  neuritis,  softening, 
tumours  ;  or  it  may  be  a  symptom  of  basal  meningitis,  apoplexy, 
intracranial  tumours,  and  other  central  affections.^ 

Masticatory  spasm  also  frequently  results  from  reflex  irrita- 
tion. The  peripheral  irritation  may  either  be  in  the  region  of 
distribution  of  one  of  the  sensory  branches  of  the  fifth  nerve,  or 
in  some  remote  part  of  the  body,  such  as  the  abdominal  organs, 
or  extremities. 

Diagnosis. — The  tonic  form  might  possibly  be  mistaken  for 
anchylosis  of  the  lower  jaw,  but  the  two  affections  can  be  readily 
distinguished  by  a  careful  examination,  and  in  cases  presenting 
unusual  difficulties  chloroform  will  aid  the  diacfnosis. 

Prognosis. — The  prognosis  is  generally  favourable  in  the 
forms  which  arise  from  exposure  to  cold,  and  from  reflex  irri- 
tation; but  it  is  unfavourable  in  diseases  of  the  central  nervous 
system,  in  severe  general  convulsions,  and  especially  in  tetanus. 

Treatment — The  treatment  must  be  directed  to  the  removal 
of  the  cause  of  the  affection.  In  rheumatic  cases,  or  those  which 
arise  from  exposure  to  cold,  active  diaphoresis,  opium,  and  iodide 
of  potassium  may  be  tried.  In  reflex  masticatory  spasm  the 
peripheral  source  of  irritation  must  be  discovered  and  removed. 

Electricity  is  the  most  valuable  agent  for  direct  treatment, 
and  the  usual  methods  of  applying  the  galvanic  or  faradic 
currents  must  be  employed. 

^  See  Lepine  (R).  "Du  trismus  d'origine  c4r4brale."  Eevue  de  medecine, 
1882,  p.  849. 


DISEASES  OF  THE  MIXED  CRANIAL   NERVES.  513 

Subcutaneous  injection  of  morphia  is  very  useful;  and  in 
obstinate  cases  nervine  tonics  may  be  given,  such  as  zinc, 
arsenic,  or  iodide  of  potassium.  The  diet  must  be  carefully 
regulated,  and  it  is  requisite  to  give  nourishment  in  a  £uid 
form,  either  by  means  of  a  tube  introduced  through  a  space  in 
the  teeth  or  through  the  nose,  or  by  the  use  of  nutritive 
enemata. 

In  chronic  cases  an  attempt  has  been  made  gradually  to 
separate  the  jaws  by  mechanical  means,  as  by  the  daily  intro- 
duction of  progressively  thicker  wedges  of  wood  between  the 
teeth.  In  a  case  under  my  care,  which  resisted  ordinary  treat- 
ment, chloroform  was  administered,  and  the  jaws  forcibly 
separated  by  means  of  a  gag.  The  spasm  did  not  subsequently 
recur. 

§  271.  Paralysis  in  the  Region  of  Distribution  of  the  Fifth 
Nerve,     Masticatory  Pa.ralysis. 

Etiology. — Paralysis  of  the  motor  branch  of  the  trigeminus  is 
rare  from  lesion  in  its  extracranial  course,  because  the  nerve  is 
so  deeply  situated  and  so  well  protected  from  injuries  and 
exposure  to  cold.  The  most  frequent  causes  of  masticatory 
paralysis  are  intracranial  lesions,  which  compress  the  motor 
branch  of  the  nerve  at  the  base  of  the  skull,  such  as  periostitis, 
exostoses,  caries,  extravasations,  and  tumours  of  all  sorts. 

Paralysis  of  this  nerve  is  also  caused  by  those  lesions  of  the 
pons  which  implicate  the  motor  root  of  the  trigeminus,  and  occa- 
sionally by  lesions  of  the  cortex  of  the  brain.^ 

Symptoms. — When  the  paralysis  is  unilateral,  there  is  diffi- 
culty or  impossibility  of  masticating  food  on  that  side,  and  the 
lateral  movements  towards  the  sound  side  are  rendered  impos- 
sible by  paralysis  of  the  pterygoids.  The  affected  muscles  are 
often  felt  to  be  wasted,  and  during  mastication  they  remain 
flaccid,  while  those  of  the  opposite  side  feel  rigid  at  each  con- 
traction. 

When  the  affection  is  bilateral  the  patient  suffers  great  fatigue 
during  mastication,  and  he  is  forced  to  eat  only  fluid  and  pulpy 
nourishment ;  and  when  the  paralysis  is  complete  the  lower  jaw 

»  See  Barlow  (T.).  "  On  a  case  of  double  hemiplegia  with  cerebral  symmetrical 
lesions."    British  Medical  Journal,  Vol.  II.,  1877,  p.  103. 

VOL.  L  H  H 


514  DISEASES  OF  THE  MIXED   CRANIAL  NERVES. 

falls  down  with  its  own  weight.  At  times  the  jaw  may  be  fixed 
by  secondary  contracture  of  the  paralysed  muscles.  The  paralysed 
muscles  may  become  atrophied,  and  they  then,  as  a  rule,  mani- 
fest the  reaction  of  degeneration. 

The  tensor  veli  palati  and  the  tensor  tympani  are  supplied  by 
the  fifth  nerve.  Unilateral  paralysis  of  the  tensor  palati  is  accom- 
panied by  elevation  of  the  palate  of  the  paralysed  side  caused  by 
the  unantagonised  action  of  the  levator  palati,  but  this  condition 
has  not  hitherto  been  observed  along  with  masticatory  paralysis. 
Deafness  is  not  unfrequently  associated  with  sensory  and  motor 
paralysis  of  the  fifth  nerve,  but  in  many  of  these  cases  the  lesion 
is  situated  in  the  pons  or  at  the  base  of  the  brain,  and  the  auditory 
nerve  is  dir-ectly  affected.  Several  cases  of  this  kind  have  come 
under  my  own  observation.  It  is,  however,  probable  that  paralysis 
of  the  tensor  tympani  causes  disorders  of  hearing  in  the  absence 
of  any  lesion  of  the  auditory  nerve;  these  consist  of  noises  in  the 
ears,^  and  a  diminished  power  of  appreciating  deep  tones,  ^ 
Masticatory  paralysis  is  rare  as  a  separate  affection.  It  is 
usually  associated  with  anaesthesia  of  the  third  division,  or  of 
one  or  more  of  the  other  divisions  of  the  trigeminus,  and  with 
paralysis  of  the  third  and  other  nerves. 

The  diagnosis  does  not  present  any  difficulty;  the  prognosis 
varies  according  to  the  cause;  and  the  treatment  comprises  the 
ordinary  means,  such  as  electrisation  and  other  remedies. 

(II.)- DISEASES  OF  THE  VAGUS,   PNEUMOGASTRIC  OR  TENTH 
CRANIAL  NERVE. 

The  pneumogastric  has  the  longest  course  of  any  of  the  cranial 
nerves,  inasmuch  as  it  extends  through  the  neck  and  cavity  of 
the  chest  to  reach  the  upper  part  of  the  abdomen.  The  nerve 
emerges  from  the  medulla  oblongata,  between  its  lateral  column 
and  the  restiform  body ;  its  roots,  twelve  or  fifteen  in  number, 
lying  beneath  and  in  a  line  with  the  roots  of  the  glosso-pharyn- 
geal  nerve. 

The  disease  of  the  pneumogastric  may  be  divided  into  those 
of  the  (A)  pharyngeal  and  oesophageal  plexuses,  (B)  the  laryngeal 
nerves,  and  (C)  the  trunk  of  the  nerve. 

1  See  Althaus  (J.),    The  Lancet.    Vol,  II.,  1868,  p.  729. 
^  Lucse.  (A.).    Berl.  Klin.  Wochenschr.    Bd.  XL,  1874,  pp,  163,  187,  and  199. 


DISEASES   OF  THE  MIXED  CRANIAL   NERVES,  515 

Fig.  54. 
F 

Fig.  54  (from  Hermann's  "  Physio- 
logy"). Diagram  of  the  Pneumogas- 
trie  and  Spinal  Accessory  Nerves,  their 
connections  and  branches. 

P,  Pneumogastric  nerve. 
SA,  Spinal  accessory  nerve. 
H,  Hypoglossal  nerve. 
GP,  Glosso-pharyngeal  nerve. 
r,  Facial  nerve. 

S,  Superior    cervical  ganglion  of   the 
sympathetic. 
gr,  Ganglion  of  the  root  of  the  vagus. 
gt.  Ganglion  of  the  trunk  of  the  vagus. 

1,  Auricular  branch  of  the  vagus 
(Arnold's  nerve). 

2,  Pharyngeal  branch. 

3,  Convergence  of  nerves  to  form 
pharyngeal  plexus. 

4,  Superior  laryngeal  nerve. 
4',  Internal  branch    of   superior 

laryngeal  nerve. 
4",  External  branch  of  superior 
laryngeal  nerve. 
6  6  6,    Cardiac   branches   of  the 
vagus. 

5,  Inferior  laryngeal  nerve  (recur- 
rent). 
6',   Cardiac   branch    of    inferior 

laryngeal  nerve. 

7,  Convergence  of  branches  of  vagus 
to  form  cardiac  plexuses. 

8,  Pulmonary  branches. 

9,  (Esophageal  branches. 

10,  Gastric  branches. 

11,  Splenic  branches. 

12,  Hepatic  branches. 
SA,  Spinal  accessory  nerve. 

id,  Internal  division  of  spinal  ac- 
cessory. 

ed,  External  division  of  spinal  ac- 
cessory. 

IC,  lie,  IIIC,  JVC,  Cervical  nerves. 


516 


DISEASES  OF  THE  MIXED  CRANIAL  NERVES. 


(A)  Diseases  of  the  Pharyngeal  and  (Esophageal  Plexuses. 

The  pharyngeal  plexus  is  composed  not  only  of  branches  of 
the  vagus,  but  also  of  the  glosso-pharyngeal  and  the  sympathetic, 
and  the  relative  function  of  each  of  these  in  the  innervation  of 
the  soft  palate  has  not  yet  been  determined.  The  levator  palati 
and  azygos  uvulse  are  supplied  from  the  seventh,  but  it  will  be 
more  convenient  to  group  together  all  the  different  forms  of 
paralysis  of  the  soft  palate,  no  matter  from  what  source  the 
muscles  derive  their  nerve  supply.  The  following  table  gives 
the  muscles  which  move  the  soft  palate,  with  their  origins  and 
insertions : — 


Name  of  Muscle. 
Levator  Palati   .     , 


Tensor  Palati  (circum- 
flexus  palati). 


Azygos  Uvulse 


Palato  Glossus  (con- 
strictor isthmi  fau- 
cium). 

Palato -pharyngeus 
(constrictor  isthmi 
faucium  posterior. 


Origin. 

Extremity  of  petrous  bone  ; 
posterior  and  inferior  as- 
pect of  Eustachian  tube. 

Scaphoid  fossa  at  base  of 
internal  pterygoid  plate. 

Spinous  process  of  sphenoid 
bone  ;  anterior  aspect  of 
Eustachian  tube. 

Spine  of  palate  bone  and  ad- 
joining tendinous  struc- 
tures. 

Soft  palate  continuous  vidth 
its  fellov?  of  the  opposite 
side. 

Raph^  of  soft  palate,  and  is 
continuous  with  its  fellow 
of  the  opposite  side. 


Insertion. 

Middle  line,  where  it  is  con- 
tinuous with  its  fellow  of 
the  opposite  side. 

Transverse  ridge  on  the 
horizontal  portion  of  the 
palate  bone,  and  the  apo- 
neurosis of  the  velum. 


Uvula, 


Side  of  Tongue. 


Posterior  border  of  the  thy- 
roid cartilage  and  side  of 
the  pharynx,  as  far  back 
as  the  middle  line. 


Nerve  Supply. — The  levator  palati  and  azygos  uvulae  receive  motor 
branches  from  the  seventh  nerve  through  the  petrosal  branch  of  the  Vidian. 
The  tensor  palati  receives  branches  from  the  otic  ganglion  ;  the  palato- 
glossus and  palato- pharyngeus  receive  branches  from  Meckel's  ganglion  and 
the  pharyngeal  plexus. 


§  272.  Actions. 

The  Azygos  Uvulce  not  only  shortens  the  uvula,  but  renders  it  hard,  and- 
draws  its  point  upwards  and  backwards  towards  the  posterior  wall  of  the 
pharynx. 

The  Levator  Palati  raises  the  soft  palate,  draws  its  free  margin  upwards, 
and  elevates  the  palatine  arch. 

The  Tensor  Palati^  acting  with  its  fellow  of  the  opposite  side,  spreads 


DISEASES  OF  THE  MIXED   CRANIAL  NERVES. 


517 


the  palate  out  laterally,  and  also  arches  it  with  its  concavity  downwards. 
Taking  its  fixed  point  from  below,  the  tensor  palati  will  dilate  the  Eusta- 
chian tube. 

The,  Palato-glossus  approximates  the  anterior  pillars  of  the  fauces  to  the 
middle  line. 

The  Pal'ito-pharyiigeus  descends  in  the  posterior  pillar  of  the  fauces, 
and  by  opposing  the  action  of  the  elevator  muscle,  it  depresses  the  velmn, 
and  both  lowers  and  narrows  the  posterior  palatine  arch. 

The  following  table  gives  the  muscles  of  the  pharynx,  their 
origins,  and  insertions  {Figs.  55,  56,  and  57)  : — 


Name, 


Superior  Constrictor - 


Middle  Constrictor 


Inferior  Constrictor 


Stylo-pharyngeus . 


Palato-pharyngeug 


Salpingo-pharjmgeus 


Origin. 

1,  The  side  of  the  tongue. 

2,  Mucous  membrane  of  the 
mouth. 

3,  Mylo-hyoid  ridge  of  jaw. 

4,  Pterygo  -  maxillary     liga- 
ment. 

5,  Lower    of    third    internal 
pterygoid  plate. 

1,  Great  comu  of  os  hyoides. 

2,  Lesser  cornu  of  os  hyoides, 

3,  Styio-hyoid  ligament. 

1,  Cricoid  cartilage. 

2,  Oblique  line  of  thyroid  car- 
tilage, 

1,  Inner  side  of  base  of  styloid 
process. 


1,  Raph^  of  soft  palate,  con- 
tinuous with  the  corre- 
sponding muscle  of  the 
opposite  side. 

1,  Lower  border  of  Eustachian 
tube. 


Insertion. 

1,  Raphe  of  pharynx. 

2,  Basilar  process  of  occi- 
pital bone  by  means  of 
pharyngeal  aponeurosis. 


1,  Raphe  of  pharynx. 


1,  Middle  line  of  pharynx. 


1,  Posterior  border  of  thy- 
roid cartilage. 

2,  Internal  face  of  inferior 
constrictor. 

1,  Inner  surface  of  the  pha- 
rynx. 

2,  Posterior  border   of   the 

thyroid  cartilage. 

1,  Unites  with  palato-pha- 
ryngeus. 


§  273.  Actions. 

The  constrictor  muscles  contract  upon  the  morsel  of  food  as  soon  as  it 
is  received  by  the  pharynx  and  convey  it  downwards  into  the  oesophagus. 
The  stylo-pharyngei  draw  the  pharynx  upwards,  and  widen  it  laterally. 
The  palato-pharyngei  also  draw  it  upwards  and  with  the  aid  of  the  uvula 
close  the  opening  of  the  fauces.  The  salpingo-pharyngei  are  elevators  of 
the  upper  part  of  the  pharynx. 

The  diseases  of  the  pharyngeal  and  oesophageal  plexuses  may 
be  divided  into  (1)  sensory,  and  (2)  motor  disorders  of  the  soft 
palate,  pharynx,  and  oesophagus. 


518 


DISEASES  OF  THE  MIXED   CRANIAL  NERVES. 


1.  Sensory  Disorders  of  the  Soft  Palate,  Pharynx,  and 
(Esophagus. 

The  sensory  disorders  of  the  pharynx  may  be  divided  into 
conditions  of  (1)  hypercesthesia,  (2)  anaesthesia,  (3)  parcesthesia, 
and  (4)  neuralgia. 

(1)  Hypercesthesia  of  the  pharynx  accompanies  acute  and 
chronic  inflammatory  conditions,  and  every  degree  of  increased 
sensitiveness  of  the  mucous  membrane  may  be  met  with  in 
hysterical  women.  This  condition  is  very  troublesome  to  the 
laryngoscopist,  and  the  existence  of  hypersesthesia  in  the 
pharyngo-nasal  region  may  render  the  introduction  of  the 
Eustachian  catheter  impossible,-^ 

(2)  Anaesthesia  of  the  mucous  membrane  of  the  pharynx  is 

Fig.    55. 


Fig.  55.     Muscles  of  the  Palate. 


1,  Septum  narium. 

2,  Eustachian  tube. 

3,  Pterygoideus  externus. 

4,  Pterygoideus  internus. 

5,  Levator  palati  mollis. 

6,  Circumflexus  palati. 

7,  Superior  constrictor  of  pharynx. 


8,  Azygos  uvula3. 

9,  Palato-pharyugeus. 

10,  Stylo-pharyngeup. 

11,  Middle  constrictor  of  pharynx. 

12,  Palato-pharyngeus  (cut). 

13,  Inferior  constrictor  of  pharynx. 

14,  (Esophagus. 


*  Mackenzie  (Morell).    A  manual  of  the  diseases  of  the  throat  and  nose.    Lond. 
1880.    p.  113. 


DISEASES  OF  THE  MIXED  CRANIAL  NERVES. 


519 


always  present  in  diphtheritic  paralysis,  and  it  forms,  aceording 
to  Krishaber,^  one  of  the  earliest  symptoms  of  progressive  bulbar 
paralysis.  Insensibility  of  the  pharynx  is  sometimes  met  with  in 
the  insane. 

Fig.  56. 


Fi&.  57.  Styloid  Muscles  and  Muscles  of 
the  Tongue  (from  Heath). 

1,  Temporal  bone  of  the  left  side. 

2, 2,  The  right  side  of  the  lower  jaw 
divided  at  its  symphysis ;  the  left 
side  having  been  removed. 

3,  Tongue. 

4,  Genio-hyoideus. 

5,  Genio-hyo-glossus. 

6,  Hyo-glossus ;  its  basio-glossus  por- 
tion. 

7,  Its  kerato-glossus  portion. 

8,  Anterior  fibres  of  the  lingualis  issuing 
from  between  the  hyo-glossus  and 
genio-hyo-glossus. 

9;  Stylo-glossus  vnih.  part  of  the  stylo- 
maxUlary  ligament. 

10,  Stylo-hyoideus. 

11,  Stylo-pharyngeus. 

12,  Os  hyoides. 

13,  Thyro-hyoid  membrane. 

14,  Thyroid  cartilage. 

15,  Thyro-hyoid  muscle  arising  from  the 

oblique  line  of  the  thyroid  cartilage. 

16,  Cricoid  cartilage. 

17,  Crico-thyroid  membrane. 

18,  Trachea. 

19,  Commencement  of  the  oesophagus. 

1  Krishaber.  "Anesth^sie  de  la  sensibility  reflexe  desvoieS' aeriennes  et  diges- 
tives comme  signe  pr^curseur  de  la  paralysie  labio-glosso-laryngde."  Gazette  hebd., 
de  med.  et  de  chir.,  2^  Serie,  Tome  IV.,  1872,  p.  772. 


1, 
2, 
3, 
4, 
5, 
6, 
7, 
8, 
9, 
10, 

11, 
12, 


13, 

14, 
15, 
16, 
17, 


Fig.  56.  Muscles  of  the  Pharynx- 

(from  Heath). 
Trachea. 
Cricoid  cartilage. 
Crico-thyroid  membrane. 
Thyroid  cartilage. 
Thyro-hyoid  membrane. 
Os  hyoides. 
Stylo-hyoid  ligament. 
CEsophagus. 
Inferior  constrictor. 
Middle  constrictor. 
Superior  constrictor. 
Stylo  -  pharyngeus,     passing    down 

between  the  superior  and  middle 

constrictor. 
Fibrous   bag  of  the  pharynx  seen 

above  the  constrictor. 
Pterygo-maxiUary  ligament. 
Buccinator. 
Orbicularis  oris. 
Mylo-hyoideus. 


520  DISEASES   OF  THE  MIXED   CRANIAL   NERVES. 

(8)  Parcesthesice  of  the  pharyngeal  mucous  membrane  are  often 
experienced  after  the  removal  of  a  foreign  body,  and  may  occur 
without  any  exciting  cause  in  hysteria.  The  patient  feels  as  if 
some  foreign  body,  such  as  a  fish-bone,  hair,  or  some  hard  sub- 
stance were  sticking  in  the  throat. 

(4)  Neuralgia  of  the  larynx  has  been  described  by  Tiirck^  and 
Mackenzie.^  Most  of  the  cases  observed  by  the  latter  author 
occurred  in  young  girls  under  twenty,  although  he  has  met  with 
the  affection  in  married  women  between  thirty  and  forty. 
Patients  complain  of  pain  of  the  soft  palate,  which  is  generally 
limited  to  one  side. 

Treatment — Hypersesthesia  of  the  pharynx  only  requires 
treatment  when  a  laryngoscopic  examination  has  to  be  made. 
Bromide  of  potassium  is  supposed  to  have  the  power  of  pro- 
ducing ansesthesia  of  the  pharynx  ;  but  Mackenzie^  accomplishes 
this  end  by  asking  the  patient  to  suck  small  pieces  of  ice  con- 
tinuously for  fifteen  or  twenty  minutes. 

Ansesthesia  may  be  treated  by  the  galvanic  current ;  the 
paraesthesise  disappear  in  a  few  days  without  treatment  unless 
they  are  symptoms  of  hysteria,  in  which  case  the  treatment 
must  be  directed  against  the  underlying  disease.  Mackenzie 
found  local  applications  of  tincture  of  aconite  an  effectual 
method  of  treatment  in  neuralgia  of  the  pharynx. 

2.   Motor  Disorders  of  the  Soft  Palate,  Pharynx,  and 
(Esophagus. 

The  motor  disorders  of  the  pharyngeal  and  oesophageal 
plexuses  may  be  divided  into  (1)  spasm;  and  (2)  paralysis  of 
the  soft  palate,  pharynx,  and  oesophagus, 

(1)  Spasm  of  the  Soft  Palate,  Pharynx,  and  CEIsophagus. 

(a)  Spasm  of  the  Soft  Palate  and  Eustachian  Tube. — 
Very  little  is  known  with  respect  to  spasm  of  the  muscles  of  the 
soft  palate  and  of  the  associated  muscular  apparatus  of  the 
Eustachian  tube.     Noises  in  the  ears  can  be  induced  in  healthy 

1  Tiirck.    Wiener  AUg.  Med.  Zeitung,  1862,  No.  9. 

'^  Mackenzie  (Morell).  A  manual  of  diseases  of  the  throat  and  nose.  Lond., 
1880.    p.  114. 

'  Mackenzie  (Morell).    Rid.,  p.  235. 


DISEASES   OF  THE  MIXED   CRANIAL   NERVES.  521 

individuals  by  the  intratubal  application  of  the  faradic  or  galvanic 
current,  caused  by  contraction  of  the  tubal  muscle.  Twitching 
movements  of  the  palate  have  sometimes  been  observed  in 
advanced  cases  of  paralysis  agitans.^ 

(6)  Spasm  of  the  Pharynx. — The  constrictors  of  the  pharynx 
are  generally  implicated  in  spasmodic  stricture  of  the  oesophagus. 
Spasm  of  these  muscles  is  also  met  with  in  acute  pharyngitis, 
and  forms  a  very  prominent  symptom  of  hydrophobia. 

(c)  (Esophagismus. — Spasmodic  stricture  of  the  oesophagus 
is  by  no  means  uncommon.  It  is  most  frequently  met  with  in 
hysterical  women,  and  some  believe  that  globus  hystericus  is 
the  subjective  correlative  of  spasm  of  the  oesophagus.  Spasm  of 
the  oesophagus  is  sometimes  so  severe  and  persistent  in  cases  of 
hysteria  as  to  simulate  organic  stricture,  and  the  patient  may  be 
reduced  to  the  verge  of  death  by  inanition.  It  may  at  other 
times  be  caused  by  irritation  in  the  peripheral  course  of  the 
nerves,  or  by  reflex  irritation  in  cases  of  ulcer  of  the  tube,  but 
it  is  rare  in  central  disease  of  the  nervous  system. 

Treatment. — ^The  treatment  must  be  directed  against  the 
primary  disease.  The  treatment  of  hysterical  cesophagismus  pre- 
sents many  difficulties ;  it  is  usually  accompanied  by  so  much 
hypersesthesia  and  general  nervousness  that  it  will  be  found 
impossible  to  pass  a  bougie,  and  the  patient  will  not  readily 
submit  to  have  chloroform.  In  aggravated  cases  which  do  not 
yield  to  ordinary  treatment  the  patient  should  be  isolated  from 
her  friends,  and  if  the  spasm  does  not  then  yield,  she  should  be 
fed  regularly  by  means  of  the  stomach  pump. 

(2)  Paralysis  of  the  Soft  Palate,  Pharynx,  and  CEsophagxjs. 

(a)  Paralysis  of  the  Soft  Palate. — Paralysis  of  the  soft 
palate  occurs  in  connection  with  bulbar  paralysis  and  in  the 
course  of  many  diseases  of  the  spinal  cord.  The  partial  paralysis 
which  occurs  in  peripheral  facial  paralysis  has  already  been 
mentioned.  The  symptoms  of  paralysis  of  the  soft  palate  differ 
according  as  the  affection  is  partial  or  complete.  Partial  paralysis 
declares  itself  more  especially  by  the  abnormal  position  of  the 
uvula  and  soft  palate,  while  total  paralysis  gives  rise  to  marked 
alterations  of  speech  and  in  the  power  of  deglutition. 

1  Wagner.    Ziemssen's  Cyclopaedia.    Vol.  VI.,  1876,  p.  993. 


522 


DISEASES   OF  THE  MIXED   CRANIAL  NERVES. 


(i.)  Paralysis  of  the  Levator  Palati. — It  has  already  been 
mentioned  that  the  levator  palati  is  paralysed  in  peripheral 
affections  of  the  facial  nerve  when  the  lesion  is  situated 
above  the  geniculate  ganglion.  The  velum  on  the  paralysed 
side  hangs  loosely  downwards,  and  occupies  a  lower  position 
during  rest  than  on  the  sound  side.  Tickling  the  uvula  does 
not  cause  it  to  be  arched  upwards ;  it  is  only  rendered  tense 
transversely  by  the  action  of  the  tensor  palati,  and  its  posterior 
edge  is  drawn  slightly  downwards  by  the  action  of  the  palato- 
pharyngeus. 

When  the  levator  palati  and  tensor  palati  a,re  simultaneously 
affected  the  soft  palate  hangs  still  deeper  on  that  side,  there  is 
also  lateral  displacement  of  the  velum  owing  to  the  unopposed 
action  of  the  tensor  palati  of  the  opposite  side,  and  reflex  action 
on  irritation  is  absent. 

Disturbances  of  phonation  and  of  deglutition,  such  as  nasal 
speech  and  regurgitation  of  fluids  through  the  nose,  are  more 
marked  than  when  the  levator  palati  is  alone  affected. 

(ii.)  Paralysis  of  the  azygos  uvulce  accompanies  paralysis  of  the 
levator  palati  in  disease  of  the  seventh  nerve  above  the  geni- 
culate ganglion.  Unilateral  paralysis  of  the  azygos  uvulae  causes 
distortion  of  the  uvula.    The  uvula  occupies  an  oblique  position, 

Fig.  58. 


Fig.  58  (after  Sanders).  Distortion  of  the  uvula,  in  a  case  of  peripheral  paralysis  of 
the  right  side  of  the  face. 


DISEASES  OF   THE  MIXED  CRANIAL   NERVES.  523 

with  its  point  usually  directed  to  the  healthy  side.^  In  a  case 
recorded  by  Sanders,^  however,  the  uvula  is  described  as  "pro- 
jecting somewhat  forwards,  and  directed  obliquely  from  left  to 
right,  the  tip  pointing  to  the  right  or  paralysed  side,  its  base 
being  in  the  middle  line,  or  perhaps  drawn  a  little  to  the  left  or 
sound  side."  Four  cases  are  described  by  Romberg,^  and  one  by 
Davaine,*  in  which  the  uvula  was  arched  with  the  convexity 
directed  to  the  sound  side,  and  the  tip  of  the  uvula  to  the 
paralysed  side,  and  I  have  myself  seen  two  well-marked  instances 
of  this  distortion.  It  is  difficult  to  account  for  the  anomalous 
position  occupied  by  the  uvula  in  these  cases.  It  has  been  sug- 
gested that  the  distortion  to  the  paralysed  side  existed  prior  to 
the  paralysis,  as  the  uvula  is  not  unfrequently  found  twisted  to 
one  side  in  healthy  persons,  but  this  could  not  have  been  the 
case  in  the  observations  of  Romberg  and  Davaine,  inasmuch  as 
the  uvula  assumed  a  symmetrical  position  as  the  patient  re- 
covered from  the  paralysis.  Sanders  thinks  that  the  drawing  of 
the  uvula  towards  the  paralysed  side  is  due  to  the  action  of  the 
palato-pharyngeus  exerting  a  greater  effect  on  the  uvula  on  the 
affected  side  than  it  can  exert  on  the  sound  side,  but  this 
explanation  is  by  no  means  satisfactory. 

(iii.)  Paralysis  of  the  palato-pharyngeus  is  recognised  by  the 
altered  appearance  of  the  isthmus  of  the  fauces,  the  posterior 
pillars  of  the  fauces  being  more  widely  separated  from  one 
another,  and  immovable.  Duchenne  believed  that  he  had  met 
with  isolated  paralysis  of  the  palato-pharyngeus ;  irritation 
still  provoked  shortening  of  the  uvula,  along  with  tension  and 
elevation  of  the  soft  palate.  The  posterior  pillars  of  the  fauces 
were  not  approximated  to  one  another,  nor  was  the  palate 
stretched  downwards  and  backwards,  so  as  to  form  a  complete 
screen  between  the  nasal  and  buccal  portions  of  the  pharynx. 
Speech  and  deglutition  were  unaffected. 

Paralysis  of  all  the  muscles  of  the  soft  palate  on  both  sides 

'  Gairdner  (W.  T.).  "Paralysis  on  both  sides  of  the  face."  The  Lancet, 
Vol.  I.,  1861,  p.  479. 

*  Sanders  (W.  R.).  "On  paralysis  of  the  palate  in  facial  palsy."  Edinburgh 
Medical  Journal,  Vol.  XI.,  1866,  p.  144. 

^  Romberg  (M.  H.).  A  manual  of  the  nervous  diseases  of  man.  Syd.  Soc, 
Vol.  II.,  1853,  p.  275. 

*  Davaine.  "  M^moire  sur  la  paralysie  gen^rale  oa  partielle  des  deux  nerfs  de 
la  septieme  paire."    Mem.  de  la  Soc.  de  Biologie,  1852,  p.  164  ;  Gaz,  Med.,  1853. 


524  DISEASES  OF  THE  MIXED   CRANIAL  NERVES. 

causes  the  palate  to  hang  loose  and  flapping  from  the  roof  of 
the  mouth,  and  its  activity  is  not  called  forth  during  deep 
inspiration,  or  during  the  movements  of  deglutition  and  phona- 
tion.  The  speech  has  a  strongly  nasal  character,  or  may  be 
quite  unintelligible,  while  fluids  are  ejected  through  the  nose. 
Deglutition  is  rendered  still  more  difficult  when  paralysis  of  the 
soft  palate  is  associated,  as  frequently  happens,  with  paralysis  of 
the  constrictors  of  the  pharynx. 

Diagnosis. — Paralysis  of  the  muscles  of  the  soft  palate  must 
be  distinguished  from  immobility  of  the  palate  caused  by  mecha- 
nical and  organic  causes.  The  position  assumed  by  the  paralysed 
parts,  the  associated  symptoms,  and  the  history  of  the  case  are 
sufficient  to  prevent  any  mistakes  being  made. 

Prognosis. — In  diphtheritic  paralysis  of  the  soft  palate  the 
prognosis  is  favourable,  while  in  the  remaining  forms  the  prog- 
nosis depends  upon  the  disease  with  which  it  is  associated,  and 
is,  as  a  rule,  unfavourable. 

Therapeutics. — The  treatment  must  generally  be  directed 
against  the  accompanying  disease.  The  local  treatment  consists 
of  the  application  of  the  faradic  or  galvanic  currents  to  the 
muscles. 

(6)  Paralysis  of  the  Pharynx  (Dysphagia  Paralytica). 

Etiology. — Paralysis  of  the  muscles  of  the  pharynx  and  of  the 
muscular  coat  of  the  oesophagus  is  rare  as  the  result  of  local 
peripheral  disease.  It  results  more  frequently  from  basal  affec- 
tions of  the  brain,  which  produce  compression  upon  the  cranial 
nerves ;  and  still  more  frequently  from  local  affections  of  the 
pons  and  medulla  oblongata.  The  paralysis  of  deglutition,  which 
accompanies  the  terminal  stages  of  progressive  muscular  atrophy, 
multiple  sclerosis,  and  other  nervous  affections,  as  well  as  the 
dysphagia  of  typhus,  and  that  which  is  always  present  during  a 
prolonged  death  agony,  probably  originate  in  local  disease  of  the 
pons  and  medulla.  Dysphagia  is  not  a  frequent  symptom  in  con- 
nection with  apoplectic  hemiplegia.  Partial  paralysis,  generally 
limited  to  the  superior  constrictor,  is  a  not  unfrequent  sequel  of 
diphtheria  and  syphilitic  affections,  and  is  generally  associated 
with  paralysis  of  the  soft  palate  and  other  muscles. 

Symptoms. — The  characteristic  symptom  of  paralysis  of  the 


DISEASES   OF  THE  MIXED   CRANIAL   NERVES.  525 

muscles  of  the  pharynx  is  difficulty  or  impossibility  of  swallow- 
ing. When  the  paralysis  is  limited  to  the  muscles  of  the 
pharynx,  and  does  not  implicate  the  facial  or  lingual  muscles, 
or  those  of  the  soft  palate,  the  loss  of  function  first  manifests 
itself  during  the  act  of  swallowing.  The  morsel  passes  along  the 
roof  of  the  mouth  and  the  back  of  the  tongue,  but  remains  on 
the  root  of  the  latter  in  the  glosso-epiglottidean  fossa,  or  even 
over  the  epiglottis;  and  must,  on  account  of  the  dyspnoea  to 
which  it  gives  rise,  be  removed  by  means  of  the  finger.  Fluids 
run  along  the  dorsum  of  the  tongue,  and  pass  readily  into  the 
larynx,  giving  rise  to  attacks  of  suffocating  cough ;  while  the 
patient  instinctively  makes  strenuous  efforts  to  pass  the  fluid 
over  the  epiglottis  by  throwing  the  head  backwards,  and  by  an 
endeavour  to  bring  the  root  of  the  tongue  as  near  as  possible  to 
the  upper  end  of  the  oesophagus.  If  the  paralysis  be  unilateral, 
the  patient  is  only  unable  to  swallow  when  the  morsel  of  food 
happens  to  lodge  on  the  paralysed  side  of  the  pharynx. 

When  there  is  only  paresis  of  the  muscles,  or  when  the  para- 
lysis is  limited  to  one  or  two  of  them,  the  power  of  swallowing 
is  only  more  or  less  diminished.  If  the  paralysis  be  limited  to 
the  superior  constrictor,  fluids  regurgitate  through  the  nose 
during  swallowing,  inasmuch  as  contraction  of  this  muscle  is 
necessary  in  order  to  complete  the  division  which  the  soft  palate 
forms  between  the  buccal  and  nasal  portions  of  the  pharynx 
during  swallowing.  This  symptom  is,  of  course,  most  pro- 
nounced when  paralysis  of  the  superior  constrictor  is  associated 
vdth  paralysis  of  the  soft  palate,  as  in  the  form  which  follows 
diphtheria. 

(c)  Paralysis  of  the  (Esophagus. 

Paralysis  of  the  oesophagus  sometimes  occurs  as  an  isolated 
affection.  The  morsel  of  food  in  such  a  case  passes  from  the 
pharynx  into  the  oesophagus,  but,  owing  to  the  failure  of  the 
peristaltic  action  of  the  latter,  it  remains  fast  in  the  cervical 
portion  of  the  tube,  or  regurgitates  into  the  cavity  of  the  mouth. 
When  it  remains  fast  in  the  oesophagus  it  may  produce  com- 
pression of  the  larynx,  and  cause  dyspnoea,  and  the  other 
symptoms  indicative  of  the  presence  of  a  foreign  body.  A  large 
morsel  of  food,  or  solid  substances  which  do  not  readily  become 


526 


DISEASES   OF   THE  MIXED  CRANIAL  NERVES. 


reduced  in  volume,  may  still  be  swallowed  as  these  make  their 
way  through  the  oesophagus  by  means  of  their  own  weight. 
This  occurs  with  the  greater  facility  because  the  tube  becomes 
readily  dilated  when  the  muscular  coat  is  paralysed. 

Difficulty  of  swallowing  may  be  present  in  various  conditions 
of  the  oesophagus,  and  more  especially  in  cases  where  there  is  a 
mechanical  obstruction ;  but  the  diagnosis  between  these  condi- 
tions and  paralysis  can  readily  be  made  by  means  of  the  sound. 

The  Prognosis  is  favourable  in  partial  diphtheritic  and  syphi- 
litic paralysis.  The  paralysis  which  arises  from  central  causes  is 
very  unfavourable,  owing  to  the  gravity  of  the  morbid  processes 
underlying  it ;  and  complete  paralysis,  whatever  its  origin,  may 
cause  death  more  or  less  suddenly  from  arrest  of  the  morsel  of 
food  in  the  oesophagus  or  air  passages.  Fatal  attacks  of  lobular 
pneumonia  are  very  liable  to  occur,  owing  to  the  passage  of 
particles  of  food  through  the  glottis,  which  find  their  way  into 
the  smaller  ramifications  of  the  bronchial  tubes. 

Treatment.  —  The  treatment  consists  mainly  in  the  local 
application  of  either  the  faradic  or  galvanic  currents  to  the 
affected  muscles.  In  every  case  where  there  is  complete 
paralysis,  the  patient  must  be  fed  by  the  stomach  tube  in  order 
to  avoid  slow  starvation  and  the  accidents  which  are  liable  to 
occur  during  attempts  at  swallowing. 

(B)  Diseases  of  the  Laryngeal  Nerves. 

§  274.  The  muscles  of  the  larynx  are  eight  in  number,  the  five 
larger  being  muscles  of  the  chorda  vocalis  and  rima  glottidis,  the 
three  smaller  being  muscles  of  the  epiglottis.  The  following 
table  gives  the  names  of  these  muscles,  with  their  origins  and 
insertions,  and  the  nerve  by  which  they  are  supplied  (Heath) : — 


Name. 
Crico-thyroideufl. 

Arytsenoideus. 


Crico-arytaenoideus 
posticus. 

Crioo-ary  tasnoid  eus 
lateralis. 


Origin. 

Cricoid   cartilage 
Ring. 


Arytsenoid  cartilage, 
concave  posterior 
surface. 

Cricoid  cartilage,  pos. 
terior  surface. 

Cricoid  cartilage,  late- 
ral border. 


Insertion. 

Thyroid  cartilage, 
lower  border  and 
cornu. 

Decussating  fibres. 


Arytsenoid  base,  pos- 
terior outer  angle. 

Arytfenoid  base,    an- 
terior outer  angle. 


Nerve. 
External  laryngeal. 


Superior  and  inferior 
laryugeals 


Inferior  laryngeal. 
Inferior  laryngeal. 


DISEASES   OF  THE  MIXED   CRANIAL   NERVES. 


527 


'Name. 
ThjTO-arytsenoideus. 

Thyro-epiglottideus. 


Arytasno-epiglottidens, 
superior. 

Arytseno-epiglottideus, 
mferior. 


O'l-igin. 

Tliyroid  cartilage,  re- 
ceding angle. 

External  surface  of 
Bacculus  laryngis. 

Apex  of  Arytsenoid 
cartilage. 

Arytsenoid  cartilage 
above  attacbmeut 
of  chorda  vocalis. 


Insertion. 

Arytfenoid,     anterior 
surface. 

Few  fibres  continued 
to  side  of  epiglottis. 

Side  of  epiglottis. 
Side  of  epiglottis. 


Nerve. 
Inferior  laryngeal. 

Inferior  laryngeal. 

Inferior  laryngeal. 

Inferior  laryngeal. 


§  275.  Actions. 

The  muscles  move  tlie  cartilages  of  the  larynx  upon  one  another  in  such 
a  manner  as  to  tighten  and  bring  together  or  to  separate  the  vocal  cords, 
and  thus  to  narrow  or  widen  the  aperture  between  them.  The  slit  between 
the  true  vocal  cords  is  called  the  glottis  vocalis,  and  the  interspace  between 
the  arytaenoid  cartilages  the  glottis  respiratoria. 

The  crioo-thyroidei  draw  the  thyroid  cartilage  downwards  on  the  cricoid 
cartilage,  and  thus  tighten  the  vocal  cords. 

The  thyro-arytcenoidei  are  parallel  to  and  attached  to  the  same  points  as 
■the  vocal  cords,  and  hence  their  contraction  renders  the  vocal  cords  less 
tense.  Some  of  the  fibres,  however,  are  inserted  into  different  points  of 
the  vocal  cords  themselves,  and  consequently  their  contraction  must  confer 
different  degrees  of  tension  upon  different  parts  of  the  cords. 

The  crico- arytcenoidei  postid  swing  the  arytsenoid  cartilages  outwards, 
so  that  both  the  glottis  respiratoria  and  the  glottis  vocalis  are  converted 
into  triangular  spaces  which,  together,  form  a  wide  rhombic  aperture 
(Fiff.  63,  II  IT). 

The  crico-arytoenoidei  laterales  are  antagonistic  to  the  postici,  and  bring 
the  arytsenoid  cartilages  back  to  their  old  position,  and  afterwards  approxi- 
mate them,  thus  narrowing  the  glottis  (Fig.  65,  IT). 

The  arytcenoidei  draw  the  arytsenoid  cartilages  together  at  their  apices 
and  posterior  edges.  If  they  act  in  concert  with  the  thyro-arytsenoid 
muscles,  both  glottis  vocalis  and  glottis  respiratoria  are  closed,  and  respira- 
tion completely  interrupted,  as  immediately  before  coughing  {Fig.  64,  IT  II). 

The  three  muscles  of  the  epiglottis  have  been  described  as  one  muscle, 
under  the  name  of  thyro-arytseno-epiglottideus.  Besides  compressing  the 
glands  of  the  saccvdus  laryngis  and  altering  the  form  of  the  cavity  itself, 
this  muscle,  by  its  contraction,  approximates  the  epiglottis  and  ar}i;senoid 
cartilages,  and  thus  assists  in  closing  the  glottis.  It  is  important  to 
remember  that  the  position  of  the  vocal  cords  during  quiet  breathing  is 
not  one  indicative  of  complete  passive  equihbrium  of  all  the  laryngeal 
muscles.  Immediately  after  death,  when  it  may  be  presumed  that  com- 
plete passive  equihbrimn  between  the  antagonistic  muscles  is  established, 
the  vocal  cords  are  found  much  nearer  the  median  hne  than  they  are 
during  quiet  breathing ;  hence  it  may  be  inferred  that  the  latter  position 
is  maintained  by  a  shght  tonic  action  of  the  abductors  of  the  glottis.     The 


528 


DISEASES  OF   THE  MIXED   CRANIAL  NERVES. 


Fig.  59. 


Fig.  60. 


Fia.  .59  (from  Landois'  "Physiologie"). 
Posterior  View  of  the  Larynx  after  Re' 
moral  of  the  Muscles. — E.,  Epiglottis, 
with  {W.)  the  cushion;  L.ar.'Cp., 
ligam.  ary.  epiglotticum ;  M.m., 
Mucous  membrane ;  C.  W.,  Wris- 
berg's  cartilages  ;  C.  S.,  Santorini's 
cartilages ;  C.aryt.,  Arytsenoid  carti- 
lage; C.C.,  Cricoid  cartilage;  P.m., 
Muscular  process  to  arytsenoid  carti- 
lage; Jv.cr.ar.,  Crico-aryteen.  ligament 
to  superior  cornu ;  C  t. ,  Inferior  cornu 
of  thyroid  cartilage;  L.ce.cr.p.i.,  Pos- 
terior inferior  Kerato-cricoid  ligament; 
C.tr.,  Cartilages  of  the  trachea;  P.m. 
tr,,  Membranous  part  of  the  trachea. 


Fm.  60  (from Landois'  "Physiologie"). 
Anterior  View  of  the  Laryna^  showing 
the  Ligaments  and  Attadiments  of  the 
Muscles. — O.h.,  Hyoid  bone;  C  th.. 
Thyroid  cartilage;  Corp.  trit..  Corpus 
triticeum ;  Lig.  thyr.- hyoid.  med., 
Ligamentum  thyro  -  hyoideum  me- 
dium; Lig.th.-h.lat.,  Ligament,  crico- 
thyroideum  medium ;  Lig.  eric,  ti'ach., 
Ligam.  crico  -  tracheale ;  M.  st.  h., 
Sterno-hyoid  muscle;  M.  th. -hyoid, 
Thyro-hyoid  muscle ;  M.st.  th.,  Sterno- 
thyroid muscle;  M.cr.-th.,  Crico-thy- 
roid  muscle. 


DISEASES   OF   THE   MIXED   CRANIAL   NERVES. 


529 


Fig.  61. 


Fig.  62. 


Fig.  61  (from  Landois'  "Physiologic"). 
Posterior  View  of  the  Larynx,  shoioing 
the  Muscles.— E. ,  Epiglottis,  with  ( W.) 
the  cushion  ;  C.  W.,  Wrisberg's  carti- 
lage ;  C.-S.,  Santorini's  cartilage ; 
Cart,  eric.,  Cricoid  cartilage;  Cornu 
sup. ,  Cornu  inf. ,  Superior  and  inferior 
comua  of  the  thyroid  cartilage  ;  M. 
ar.  tr. ,  Transverse  arytasnoid  muscles ; 
M.  ar.  obL,  Obliquearytsenoidmuscles; 
M.  cr.  aryt.  post,  Crico-arytsenoidei 
postici  muscles;  Pars,  cart..  Cartila- 
ginous, and  Pars.  mem. ,  Membranous 
parb  of  the  trachsea. 


Fig.  62  (from  Landois'  "  Physiologie ''). 
I'he  Laryngeal  Nerves. — O.h.,  Hyoid 
bone;  C.i/i.,  Thyroid  cartilage  ;  C.c., 
Cricoid  cartilage  ;  Tr.,  Trachea  ;  M. 
cr.-ar.  p.,  Crico  arytsenoideus  posti- 
cus muscle;  M.  cr.-ar.  I.,  Crico-arytae- 
noideus  lateralis  muscle;  M.  cr.  th., 
Crico-thyroid  muscle ;  N.  lar.  sup. 
v.,  Superior  laryngeal  nerve  of  the 
vagus,  R.  I.,  Internal  branch,  E.  E., 
External  branch ;  N.  L.  E.  v.,  Recurrent 
laryngeal  nerve,  E.  I.  N.  L.  e.,  Internal 
branch ;  E.  E.  N.  L.  R.,  External  branch 
of  the  recurrent  laryngeal  nerve. 


VOL.  L 


II 


530 


DISEASES   OF  THE  MIXED   CRANIAL   NERVES. 


glottis  assumes  various  forms  according  to  circumstances,  and  it  has  been 
found  iiseful  to  affix  definite  names  to  some  of  these.  Passing  from  the 
middle  line  outwards  these  positions  are  :  (1)  Complete  closure  of  the 
glottis  {Fig.  64,  //  Zi),  such  as  is  produced  by  the  combined  action  of  the 

Fig.  63. 


Fig.  63.  Schema  of  a  Horizontal  Section  through  the  Larynx. — //,  The  position  of 
the  arytfflnoid  cartilages  and  vocal  cords  during  quiet  breathing.  The  arrows 
indicate  the  direction  in  which  the  crico-arytfenoidei  postici  muscles  act.  //  II, 
Position  of  the  arytsenoid  cartilages  in  consequence  of  contraction  of  these 
muscles. 

Fig.  64. 


Fig.  64  (from  Landois'  "  Physiologic  ").  Schema  of  a  Horizontal  Section  through  the 
Larynx,  showing  the  action  of  the  Arytoiuoid  Muscles.— I  I,  Position  of  the 
arytsenoid  cartilages  during  quiet  breathing.  The  arrows  show  the  direction  of 
the  action  of  the  muscles.  //  //,  Portion  of  the  cartilages  when  the  muscles 
are  contracted. 


DISEASES   OF  THE  MIXED   CRANIAL   NERVES. 


531 


ary taenoidei  and  crico-arytsenoidei  muscles ;  (2)  the  cadaveric  position,  so 
called  from  being  the  position  in  which  the  vocal  cords  are  found  in  the 
dead  body,  this  position  being  one  in  which  the  vocal  cords  are  slightly 
removed  from  the  median  line,  and  consequently  the  glottis  slightly  open ; 
(3)  the  position  of  quiet  breathing,  in  which  the  glottis  is  more  open  than 
in  the  last  position,  but  is  still  only  moderately  dilated  {Fig.  63,  /  /) ; 
and  (4)  the  position  of  deep  inspiration^  in  which  the  glottis  is  widely 
dilated  (i?'i^.  QZ,  11 II). 

§  276.  Innervation  of  the  Larynx. — ^The  nerves  of  the  larynx  are  sup- 
plied from  the  superior  laryngeal  and  the  inferior  or  recurrent  laryngeal 
branches  of  the  pneumogastric  nerves,  these  being  joined  by  sympathetic 
branches.  The  superior  laryngeal  nerve  supplies  sensation  to  the  larynx 
above  the  level  of  the  vocal  cords,  motor  power  to  the  crico-thyroid  muscle, 
and  partly  also  to  the  epiglottic  muscles.  The  inferior  laryngeal  nerve  is 
purely  a  motor  nerve,  and  supplies  in  part  the  arytsenoid  muscles,  and  all 
the  other  muscles  of  the  larynx  except  the  crico-thyroid. 

The  diseases  of  the  laryngeal  nerves  may  be  divided  into  (1) 
sensory,  and  (2)  motor  affections  of  the  larynx. 

(1)  Sensory  Affections  of  the  Larynx. 

The  sensory  disturbances^  may  be  divided  into  conditions  of 
hypetwsthesia,  anwsthesia,  parcesthesia,  and  neuralgia. 

Fig.  65. 


Fig.  65  (from  Landois'  "Physiologic").  Schema  of  Horizontal  Section  through  the 
Larynx,  illustrating  the  action  of  Crico-ari/tcenoidei  laterales  Muscles. — II II, 
Position  of  the  arytsenoid  cartilages  during  quiet  breathing.  The  arrows  show 
the  direction  in  which  the  muscles  act.  /  /,  Position  of  the  cartilages  when 
the  muscles  are  contracted. 

'  See  JurasE  (A. ).     Ueber  Sensibilitats  neurosen  des  Rachens  und  des  Kehlkopfea. 
Volkmann's  Samml.  klin.  Vortrage  (Biblio),  No.  195,  Leipzig,  1881,  p.  1733. 


532  DISEASES   OF   THE   MIXED   CRANIAL   NERVES. 

(a)  HyperGesthesia  of  the  laryngeal  mucous  membrane  gives 
rise  to  excessive  reflex  actions  on  slight  causes.  A  paroxysmal 
cough  occurring  in  the  female  sex  often  depends  upon  excessive 
sensitiveness  of  the  laryngeal  mucous  membrane,  and  public 
speakers  are  liable  to  suffer  from  hypersesthesia  of  the  larynx. 

(6)  Ancesthesia  of  the  larynx  is  rare  as  an  isolated  affection, 
but  it  is  sometimes  present  in  diphtheritic  paralysis,  and  may  be, 
in  association  with  ansesthesia  of  the  pharynx,  one  of  the  earliest 
symptoms  of  bulbar  paralysis. 

(c)  ParcesthesioB  of  the  laryngeal  mucous  membrane  are  not 
unfrequently  complained  of.  These  may  at  times  consist  of  a 
feeling  as  if  a  hair,  fish-bone,  or  morsel  of  food  had  lodged  in 
the  larynx,  while  laryngoscopic  examination  shows  the  absence 
of  a  foreign  body.  Cases  of  this  nature  are  most  frequently  met 
with  in  hysterical  women. 

(d)  Neuralgia  of  the  larynx  is  rare  ;  it  occasionally  occurs  as 
a  sequel  to  laryngitis  or  from  exposure  to  cold. 

Treatment. — When  the  sensory  disorder  is  associated  with 
hysteria  or  other  disease  of  the  central  nervous  system  the 
treatment  must  be  directed  against  the  primary  affection.  In 
such  cases  constitutional  treatment,  change  of  air  and  scene,  and 
sea  bathing  are  likely  to  prove  the  most  effectual  remedies. 
When  the  disease  is  purely  local,  electrical  currents  and  local 
astringent  solutions  may  be  employed.  In  painful  affections  a 
solution  of  bromide  of  potassium  may  be  applied  locally,  while 
the  drug  is  administered  at  the  same  time  internally.  Mackenzie 
has  found  morphia  and  chloroform  most  useful  in  such  cases. 

(2)  Motor  Affections  of  the  Larynx. 
Motor  disturbances  of  the  larynx  are  much  more  important 
and  frequent  than  sensory  affections.     The  motor  affections  of 
the  larynx  may  be  divided  into  (1)  spasm,  and  (2)  paralysis  of 
the  laryngeal  muscles. 

(1)  Spasmodic  Affections  of  the  Laryngeal  Muscles. 
Tonic  Spasm  of  the  Laetisgeal  Muscles  (Laryngismus  Stridulus). 
During   spasm  of  the  laryngeal  muscles  the  action  of  the 
adductors  predominate  over  that  of  their  antagonists,  and  the 
glottis  becomes  completely  closed. 


DISEASES   OF  THE  MIXED  CRANIAL   NERVES.  533 

(i.)  Spasm  of  the  Glottis  in  Infants,  or  Internal  Convulsions. 

aetiology. — The  causes  which  predispose  to  spasm  of  the 
glottis  ai'e  generally  the  same  as  those  which  tend  to  pro- 
duce eclampsia,  and,  indeed,  the  two  diseases  frequently  coexist. 
Out  of  fifty-two  cases  analysed  by  Henoch,^  spasm  of  the  glottis 
and  eclamptic  seizures  were  present  together  in  twenty-nine ; 
while  eclampsia  alone  was  present  in  fourteen,  and  spasm  of  the 
glottis  in  nine  cases.  Spasm  of  the  glottis,  however,  is  seldom 
observed  in  persons  above  one  year  of  age,  and  usually 
attacks  children  between  four  and  ten  months.  It  is  much 
more  frequent  in  boys  than  girls ;  it  attacks  almost  exclu- 
sively the  children  of  the  poorer  classes,  and  badly-nourished 
cachectic  or  rachitic  children.  It  also  appears  more  frequently- 
in  cold  weather,  and  especially  in  the  month  of  March.  All 
authors  insist  upon  the  preponderating  influence  of  rickets  in 
the  production  of  this  disease.  Out  of  fifty  infants  attacked 
by  spasm  of  the  glottis  observed  by  Dr.  Gee,^  forty-eight  were 
rachitic.  The  irritation  of  teething,  and  the  presence  of  worms 
or  other  irritating  substances  in  the  alimentary  canal,  may  act 
both  as  exciting  and  predisposing  causes  of  spasm  of  the  glottis. 
Spasm  may  also  be  produced  by  causes  acting  at  a  distance, 
examples  of  which  may  be  found  in  the  irritation  of  teething, 
or  in  the  presence  of  parasites  or  other  irritating  substances  in 
the  alimentary  canal. 

Cold  is  the  most  frequent  exciting  cause.  It  acts  either 
directly  on  the  terminations  of  the  nerves  of  the  laryngeal  mucous 
membrane,  or  indirectly  by  producing  a  laryngo-tracheal  catarrh. 
Fatigue  of  the  muscles  of  the  larynx  caused  by  prolonged  and 
excessive  crying  is  sometimes  an  exciting  cause  of  spasm  of  the 
glottis.  When  the  disease  is  once  established  an  attack  may  be 
provoked  by  the  most  various  causes,  as  by  examination  of  the 
throat,  attempts  at  deglutition,  or  sudden  waking  from  sleep. 

Symptoms. — The  attack  generally  begins  without  premonitory 
symptom,  and,  according  to  West,^  occurs  more  frequently  in  the 

^  Henoch.  "  Ueber  den  Stimmritzenkrampf  der  Kindem."  Berl.  klin.  Wochen- 
schr.,  Bd.  IV.,  1867,  p.  201. 

2  Gee.  "  On  convulsions  in  children."  St.  Barthol.  Hosp.  Reports,  Vol.  III., 
p.  101. 

^  West.  Lectures  on  the  diseases  of  infancy  and  childhood.  6th  Edit.  Lond., 
1874.    p.  194. 


534?  DISEASES  OF  THE  MIXED  CRANIAL  NERVES. 

night  than  in  the  day.  Spasm  of  the  glottis  manifests  itself  by 
a  sudden  arrest  of  respiration ;  the  face  becomes  turgid,  the 
countenance  expresses  great  anxiety,  the  mouth  is  widely  open 
as  if  to  make  a  deep  inspiration,  the  head  is  drawn  backwards, 
the  eyes  are  fixed,  the  face  becomes  blue,  and,  in  a  word,  the 
infant  presents  all  the  characteristics  of  commencing  suffocation. 
The  respiration  may  be  suspended  from  two  to  twenty  seconds, 
and  the  end  of  the  attack  is  announced  by  a  series  of  sonorous 
inspirations,  as  if  air  were  drawn  through  a  narrow  reed.  The 
last  inspiration  becomes  longer  and  less  sonorous,  and  then  the 
respirations  assume  their  natural  rhythm.  The  sonorous  inspira- 
tion is  pathognomonic  of  spasm  of  the  glottis,  and,  once  heard, 
it  is  not  easily  forgotten.  The  condition  of  expiration  is  variable. 
In  some  cases  it  is  short  and  difficult  at  first,  but  gradually 
assumes  its  normal  characters.  In  other  cases  the  successive  in- 
spirations are  followed  by  a  series  of  short,  sonorous,  and  jerky 
expiratory  convulsions.  In  some  exceptional  cases,  again,  each 
sonorous  inspiration  is  followed  by  a  forced  and  noisy  expiration, 
and  only  very  rarely  do  the  expiratory  shocks  constitute  the  initial 
phenomenon. 

Concomitant  Symptoms. — The  functions  of  the  body  generally 
undergo  a  temporary  disturbance.  The  pulse  becomes  acceleratedj 
small,  and  sometimes  scarcely  appreciable ;  the  action  of  the 
heart  is  tumultuous  and  irregular;  and  the  chest  is  fixed.  The 
veins  of  the  neck  and  face  become  swelled,  the  skin  is  covered 
with  a  cold  sweat,  and  the  motions  may  be  passed  involuntarily. 
General  epileptiform  convulsions  are  only  observed  at  the  end 
of  the  attack,  and  not  unless  the  spasm  has  been  intense  and 
prolonged.  Spasm  of  the  muscles  of  the  extremities  is,  on  the 
contrary,  one  of  the  symptoms  habitually  present  during  the 
attack,  and  it  sometimes  precedes  the  laryngeal  spasm  by  some 
hours  or  days.  The  spasm  appears  to  depend  on  the  same 
general  causes  as  that  of  the  glottis.  It  is  ordinarily  limited  to 
flexion  of  the  hand  and  extension  of  the  feet ;  but  in  some  rare 
cases  it  invades  the  arms,  thighs,  and'trunk. 

Course  and  Terminations. — The  disease  may  be  limited  to  a 
single  paroxysm  or  to  a  series  of  paroxysms  succeeding  each  other 
for  some  hours,  and  constituting  a  single  attack  ;  but  this  is  the 
exception.     Usually  it  is  composed  of  a  series  of  paroxysms 


DISEASES   OF   THE  MIXED   CRANIAL   NERVES,  535 

coming  on  at  irregular  intervals  during  days  or  weeks.     The 
following  periods  may  be  distinguished  : — 

(1)  A  period  of  augmentation,  during  which  the  attacks  are 
rare,  brief,  and  separated  by  intervals  of  perfect  health.  This 
period  continues  generally  for  some  days,  towards  the  end  of 
which  the  attacks  become  more  frequent  and  augment  in  inten- 
sity, and  then  the  general  health  begins  to  suffer. 

(2)  A  stationary  period,  during  which  the  disease  acquires  its 
maximum  intensity;  the  infant  sometimes  dies  at  this  time, 
during  a  violent  attack,  from  suffocation,  or  succumbs  to  maras- 
mus or  nervous  exhaustion  after  repeated  attacks. 

(3)  When  the  infant  survives,  there  is  a  period  of  decline 
during  which  the  attacks  lose  their  violence,  become  shorter,  and 
are  not  so  frequently  repeated.  The  disease  then  terminates  in 
complete  recovery  after  a  total  duration  of  about  from  one  week 
to  two  months,  but  relapses  not  unfrequently  occur. 

Morbid  Anatomy  and  Physiology. — No  anatomical  changes 
beyond  congestion  of  the  membranes  of  the  brain  have  been  dis- 
covered. Spasm  of  the  glottis  appears  to  be  entirely  due  to  an 
irritable  condition  of  the  respiratory  centre  itself,  or  to  a  dis- 
charge from  the  cortex  of  the  brain  directed  towards  the  medulla 
oblongata. 

Diagnosis. — The  diagnosis  of  spasm  of  the  glottis  is  easy 
when  the  physician  happens  to  be  present  during  the  attack. 
The  diagnosis  is  assisted  by  noticing  the  perfect  health  of  the 
infant  in  the  intervals  between  the  attacks. 

Prognosis. — The  mortality  of  spasm  of  the  glottis  is  generally 
very  high.  Gooch  estimated  it  at  S3  per  cent ;  out  of  fifty  cases 
observed  by  Reid^  there  were  six  deaths,  and  of  the  fifty-two 
cases  analysed  by  Henoch^  four  only  died.  Reid  states  that  the 
disease  is  much  more  likely  to  prove  fatal  in  male  than  in 
female  children,  and  that  the  danger  is  much  greater  during  the 
period  of  dentition  than  at  any  other  time.  Rilliet  and  Barthez^ 
indicate  as  favourable  circumstances  brevity  of  the  attacks  with 
a  considerable  interval  between  them,  the  presence  of  an  expira- 

*  Reid  (James\     On  infantile  laryngismus.     London,  1849.     p.  101. 

'^  Henoch.  "  Ueber  den  Stimmritzenkrampf  der  Kindern."  Berl.  Win. 
Wochenschr.,  Bd.  IV.,  1867,  p.  201. 

*  Rilliet  et  Barthez.  Traite  clinique  et  pratique  des  maladies  des  enfants. 
Tome  II.   1853,  p.  515. 


536  DISEASES   OF  THE  MIXED   CRANIAL   NERVES. 

tion  following  each  inspiration,  the  absence  of  signs  of  asphyxia, 
female  sex,  good  hygienic  and  constitutional  antecedents.  The 
same  authors  regard  the  following  as  dangerous  symptoms :  great 
length  and  violence  of  the  paroxysm,  cyanosis  or  great  pallor  of 
the  face,  excessive  smallness  and  feebleness  of  the  pulse,  repe- 
tition, of  the  attack  after  a  very  short  interval,  that  is,  after 
half  or  three-quarters  of  an  hour,  even  if  the  first  attack  has  not 
been  a  severe  one,  and  great  nervous  exhaustion,  loss  of  appetite, 
and  wasting  from  the  frequent  recurrence  of  the  attacks. 

Treatment — During  the  attack  plenty  of  fresh  air  should  be 
allowed  to  circulate,  and  all  clothing  should  be  removed  from  the 
throat.  If  the  paroxysm  be  prolonged,  the  infant  may  be  allowed 
to  inhale  a  few  drops  of  chloroform.  If  the  infant  is  in  a  state 
of  asphyxia,  life  must  not  be  despaired  of  too  soon,  but  every 
means  for  restoring  suspended  animation  should  be  adopted, 
such  as  flapping  the  face  with  a  wet  towel,  sprinkling  cold  water 
on  the  face,  electricity,  and  artificial  respiration. 

In  order  to  prevent  a  return  of  the  attack  tonic  treatment 
must  be  adopted,  as  iron  and  cod-liver  oil ;  the  digestion  must 
be  carefully  attended  to,  and  good  nourishing  diet  prescribed. 
The  usual  nervine  remedies,  as  valerian,  assafsetida,  and  zinc, 
have  not  been  found  of  much  use  in  the  disease.  Warm  baths 
are  frequently  useful,  and  the  steam  appears  to  exercise  a 
soothing  influence  on  the  local  spasm.  During  the  attack  a 
sponge  wrung  out  of  hot  water  may  be  applied  to  the  throat. 

(ii.)  Spasm  of  the  Glottis  in  Adults. 

Spasm  of  the  glottis  in  adults  may  occur  as  a  reflex  pheno- 
menon from  local  disease  of  the  larynx  such  as  oedema  or  polypi, 
or  from  primary  disease  of  the  nervous  mechanism  itself;  it  is 
with  the  latter  alone  that  we  have  to  do  here.  This  affection  is 
usually  met  with  in  hysterical  women,^  and  paroxysms  of  hysteria 
generally  culminate  in  a  deep  stridulous  inspiration  which  in 
severe  cases  is  followed  by  temporary  arrest  of  respiration  and 
opisthotonos.^    Irritation  of  one  of  the  recurrent  or  pneumogastric 

'  Johnson  (Geo.).  "Spasm  of  the  larynx."  British  Medical  Journal,  Vol.  I., 
1871,  p.  469. 

'^  See  Mackenzie  (Morell).  A  manual  of  diseases  of  the  throat  and  nose.  Lond., 
1880.     p.  489. 


DISEASES   OF   THE   MIXED   CRANIAL   NERVES.  537 

nerves  by  enlarged  cervical  and  bronchial  glands  may  give  rise 
to  an  attack,  but  compression  of  the  nerves  by  tumours  of  all 
kinds  soon  causes  paralysis.  Spasm  of  the  laryngeal  muscles  may 
also  be  caused  in  a  reflex  manner  by  the  inhalation  of  irritating 
gases  and  the  entrance  of  morsels  of  food  into  the  larynx.  On 
laryngoscopic  examination  the  mucous  membrane  may  appear 
healthy  or  slightly  congested/  and  the  vocal  cords  may  be  seen 
separating  for  an  instant  and  then  becoming  spasmodically 
approximated, 

(iii.)  Spasm  of  the  Tensors  of  the  Vocal  Cords  {Ai^honia 

Spastica). 

This  condition  does  not  interfere  with  the  respiratory  function 
of  the  larynx,  but  the  voice  is  rendered  feeble,  jerky,  and  intermit- 
tent. The  patient  may  speak  a  few  words  in  a  normal  voice,  but 
the  current  of  the  voice  is  soon  partially  interrupted,  and  the 
sound  becomes,  according  to  Mackenzie,^  "much  like  the  straining 
and  rather  suppressed  voice  of  a  person  engaged  in  some  act 
requiring  the  prolonged  and  steady  action  of  the  expiratory 
muscles  (parturition,  defsecation)."  The  affection  was  first  de- 
scribed by  Schnitzler^  in  1875,  and  cases  have  since  been 
reported  by  Schech,*  Jurasz,^  and  others.  A  case  of  intermittent 
voice  came  under  my  observation  a  few  years  ago,  which  puzzled 
me  very  much  at  the  time,  but  which  I  now  suspect  was  an 
instance  of  this  disease. 

(iv.)  Spasmodic  Laryngeal  Cough. 

Laryngeal  cough  may  be  caused  by  hypersesthesia  of  the 
mucous  membrane,  but  the  form  under  consideration  at  present 
is  caused  by  spasm  of  the  muscles.  It  consists  of  a  shrill  or 
barking  cough  of  metallic  quality,  which  comes  on  in  paroxysms 
and  lasts  for  many  hours,  only  ceasing  when  the  patient  sleeps. 

1  Hack  (W.).      "  Ueber  respiraiorischen  und  phonischen  Stiramritzenkrampf." 
Wien.  med.  Wochenschr. ,  Bd.  XXXII.,  1882,  pp.  33  and  62,  92,  125. 
^  Mackenzie.     Op.  cit.,  p.  493. 
3  Schnitzler.     "  Aphonia  spastica."    Wiener  Med.  Presse,  1875,  Nr.  20  u,  23. 

*  Schech.  "Ueber  phonischen  Stimmritzenkrampf."  Aerztl.  Intelligenzbl., 
1879,  Nr.  24. 

*  Jurasz  (A.).  "Ueber  den  phonischen  Stimmritzenkrampf."  Deutsches  Arch, 
f.  klin.  Med.,  Bd.  XXVI.,  1880,  p.  157. 


538  DISEASES   OF   THE  MIXED   CRANIAL  NERVES. 

Tbis  cough  generally  occurs  in  young  girls  from  sixteen  to 
twenty  years  of  age,  but  it  is  sometimes  met  with  in  boys  at 
the  same  age  and  in  younger  children.  When  this  cough  occurs 
in  children  it  is  very  liable  to  be  regarded  as  the  early  stage  of 
true  croup,  and  unnecessary  alarm  is  not  un frequently  caused 
by  it.  Mackenzie^  did  not  find  any  abnormal  appearances  on 
laryngoscopic  examination.  The  paroxysmal  cough  of  hooping 
cough  should  be  described  here  as  being  caused  by  an  irritation, 
either  direct  or  reflex,  of  the  laryngeal  nerves.  The  attack 
begins  with  a  deep  inspiration,  which  is  followed  by  a  succession 
of  short  and  frequently  repeated  coughs  with  no  intervening 
inspirations ;  when  the  chest  is  contracted  to  the  utmost,  and  its 
walls  have  been  reduced  to  a  condition  of  extreme  expiration,  so 
that  the  patient  seems  almost  on  the  verge  of  asphyxia,  another 
deep  inspiration  is  taken,  during  which  the  air  rushing  through 
the  spasmodically  closed  glottis  makes  a  characteristic  whistling, 
crowing,  or  hooping  noise.  But  inasmuch  as  hooping  cough  is 
an  infectious  disease,  we  shall  not  enter  upon  a  further  considera- 
tion of  it  in  this  place. 

(v.)  Tabetic  Laryngeal  Crises. 

The  course  of  locomotor  ataxy  is  liable  to  be  complicated  by 
paroxysms  of  spasmodic  cough,  which  were  first  described  by 
Ferdol,^  and  named  by  him  laryngeal  crises.  A  case  of  the 
affection  was,  indeed,  described  by  Cruveilhier,^  but  he  did  not 
recognise  that  the  laryngeal  affection  was  anything  but  an  acci- 
dental complication  of  ataxia.  These  attacks  consist  of  a 
spasmodic  cough  not  unlike  that  of  hooping  cough,  and  their 
variable  intensity  has  led  Cherchevsky^  to  divide  them  into 
three  classes :  (a)  the  mild,  (5)  the  medium,  and  (c)  the  severe 
crises. 

(a)  The  mild  form  consists  of  fits  of  coughing  caused  by  a 
series  of  short  rapid  expiratory  efforts,  and  followed  by  a  deep 

'  Mackenzie.     Op.  cit.,  p.  491. 

^  F^r^ol.  "De  quelques  symptomes  visc^raux  et  en  particulier  des  symptomes 
laryngo- bronchi ques  de  I'ataxie  locomotrice  progressive."  L'union  Medicale, 
Tome  VII.,  1869,  pp.  39  et  51. 

^  Cruveilhier.     Anatomic  Pathologique.    Tome  II.,  1833  4,  Livraison  32,  p,  19. 
*  Cherclievsky.        "Contribution  a   I'^tude  des  crises   laryngdes  tabftiques." 
Eevue  de  Medicine,  Tome  I,,  1881,  p.  541. 


DISEASES   OF  THE  MIXED   CRANIAL   NERVES.  539 

whistling  inspiration  very  similar  to  paroxysms  of  hooping 
cough.     The  duration  varies  from  a  few  seconds  to  about  ninety. 

(6)  The  medium  form  is  characterised  by  a  more  violent  cough, 
and  a  louder  and  more  difficult  inspiration ;  the  face  and  eyes 
become  congested,  and  the  attack  is  often  accompanied  by  head- 
ache, nausea,  or  vomiting.  The  duration  of  the  attack  is  from 
five  to  ten  minutes, 

(c)  The  severe  form  is  manifested  by  symptoms  of  asphyxia, 
unconsciousness,  and  epileptiform  convulsions,  and  the  attack 
may  last  from  half-an-hour  to  several  hours.  The  attack  may 
be  excited  by  a  current  of  air,  sudden  exertion,  or  a  slight 
catarrh ;  it  may  come  on  suddenly  in  the  middle  of  a  conver- 
sation, or  during  sleep,  and  often  without  warning ;  but  at  other 
times  the  patient  may  feel  a  scalding  sensation  or  a  feeling  as  if 
a  foreign  body  were  lodged  in  the  larynx  immediately  before  the 
attack.  The  attacks  vary  greatly  in  their  periods  of  recurrence ; 
they  are  more  frequent  during  the  day  than  during  the  night,  and 
sometimes  they  may  be  repeated  as  many  as  fifty  times  in  the 
twenty-four  hours.  Laryngoscopic  examination  reveals  no  change 
beyond  spasm  of  the  glottis,  although  Krishaber  thinks  that  the 
spasm  is  associated  with  a  certain  degree  of  paralysis  of  some 
of  the  muscles. 

Laryngeal  crises  may  appear  at  an  early  period  of  locomotor 
ataxy,  and  when  present  they  often  constitute  the  most  urgent 
symptom  of  the  disease.  In  one  case  a  post-mortem  examina- 
tion revealed  grey  degeneration  of  the  posterior  columns  of  the 
spinal  cord  and  of  the  restiform  bodies  ;^  and  in  a  second  case, 
atrophy  of  the  roots  of  the  pheumogastric  and  spinal  accessory 
nerves,  sclerosis  of  the  posterior  pyramids,  and  a  focus  of  soften- 
ing in  the  left  restiform  body  were  found.^  It  is  believed  by 
Charcot  that  the  cough  is  of  reflex  origin  caused  by  hypersesthesia 
of  the  mucous  membrane  of  the  larynx;  but  it  is  equally  likely 
to  be  caused  by  irritation  of  the  central  end  of  the  spinal  acces- 
sory and  pneumogastric  nerves  in  the  medulla  oblongata,  but 
these  two  views  are  not  necessarily  antagonistic. 

'  Cruveilhier.     Loc,  cit.,  p.  20. 

"Jean.  "Des  troubles  larynges  et  pharyngeus  dans  I'ataxie  locomotrice." 
BuU.  Soc.  Anat.  de  Paris,  Tome  LII,,  1877,  p.  6]4:  Progres  Med.,  Tome  V., 
1877,  p.  93. 


540  DISEASES   OF  THE  MIXED  CRANIAL  NERVES. 

(vi.)    Clonic  Spasm  of  the  Laryngeal  Muscles  {Chorea  of  the 

Larynx). 

In  some  cases  the  laryngeal  muscles  contract  during  attempts 
at  phonation  in  such  a  way  that  the  glottis  is  alternately  closed 
and  opened  in  an  irregular  manner,  so  that  the  power  of 
inflecting  the  voice  is  diminished.  Gerhardt  mentions  the  case 
of  a  flutist  who  was  not  able  to  play  liis  instrument  without 
a  continuous  noise  being  caused  in  his  throat.  Durino^  this 
time  it  was  found  that  the  thyroid  and  cricoid  cartilages  were 
approximated,  and  the  vibration  of  the  vocal  cords  was  dis- 
tinctly perceptible  on  the  surface.  Involuntary  movements  also 
occurred  in  the  arm  which  held  the  flute.  These  movements 
appear  to  have  been  produced  by  an  immoderate  use  of  the 
instrument,  and  ceased  after  treatment  with  rest  and  bromide 
of  potassium.  Gerhardt  thinks  that  this  case  is  analogous  to 
professional  spasms  in  the  hand ;  and,  indeed,  this  patient  had 
at  a  previous  period  suffered  from  writers'  cramp.  The  laryngeal 
muscles  are  subject  to  clonic  spasms  in  chorea,  and  the  disorderly 
contractions  may  in  some  cases  be  so  aggravated  that  the  patient 
can  only  utter  a  succession  of  grunts  or  other  inarticulate  sounds. 
In  cases  of  double  athetosis,  the  laryngeal  muscles  are  liable  to  be 
implicated  in  the  spasm,  and  they  are  also  occasionally  affected 
by  incoordinate  movements  in  ataxia. 

(2)    Paralysis  of  the  Laryngeal  Branches  of  the  Vagus 
(Paralysis  of  the  Larynx — Aphonia  Paralytica). 

Etiology. — Paralysis  of  the  laryngeal  muscles  is  generally  of 
peripheral  origin.  The  more  usual  causes  are  traumatic  lesions, 
such  as  arise  from  gunshot  injuries  and  surgical  operations. 
Compression  of  the  trunk  of  the  vagus  or  of  the  recurrent 
laryngeal  nerve  by  various  tumours,  such  as  enlarged  lymphatic 
glands  in  the  neck,  aneurism  of  the  carotid  and  subclavian 
arteries,  and  mediastinal  tumours,  cancer  of  the  oesophagus, 
trachsea,  or  thyroid  gland,^  is  the  most  frequent  cause  of  paralysis. 
It  results  occasionally  from  bilateral  compression  of  the  spinal 

1  Byers.    British  Medical  Journal,  Vol.  I.,  1882,  p.  542. 


DISEASES   OF  THE  MIXED   CRANIAL  NERVES.  541 

accessory  uerve  in  its  passage  through  the  foramen  lacerum  by 
cancerous  infiltration  at  the  base  of  the  skull.^ 

Paralysis  of  the  larynx  is  sometimes  caused  by  exposure  to  a 
draught  of  cold  air,  and  by  excess  of  functional  activity  from 
prolonged  speaking,  screaming,  or  singing. 

Paralysis  of  the  vocal  cords  occurs  as  a  sequel  of  acute  diseases 
as  typhus,  cholera,  rheumatism,  and  diphtheria,  as  well  as  in 
syphilis,  and  in  chronic  lead  and  arsenical  poisoning.  Hysteria 
is  one  of  the  most  frequent  causes  of  this  affection.  Paralysis 
of  the  adductors  of  the  vocal  cords  with  its  resulting  aphonia  is, 
indeed,  one  of  the  most  common  symptoms  of  hysteria,  although 
a  case  is  recorded  by  Woakes,^  which  seems  to  show  that  para- 
lysis of  the  abductors  with  great  respiratory  dififiulty  may  occa- 
sionally take  place.  Laryngeal  paralysis  from  organic  disease  of 
the  nerve  centres  is  rare,  but  it  sometimes  occurs  in  the  course 
of  tabes  dorsalis,  insular  sclerosis,  and  progressive  bulbar  paralysis. 
Unilateral  paralysis  of  the  vocal  cords  sometimes  results  from  an 
apoplectic  seizure  when  the  lesion  is  situated  in  the  medulla 
oblongata. 

Symptoms. — The  larynx  contains,  on  the  one  hand,  the  organs 
of  voice  and  speech,  and,  on  the  other,  it  provides  a  free  opening 
for  the  passage  of  air  during  respiration.  Paralysis  of  the  laryn- 
geal muscles,  therefore,  gives  rise  to  two  prominent  symptoms 
corresponding  to  the  double  function  of  the  organ  ;  the  first  con- 
sists of  disturbances  of  voice  and  speech,  and  the  second  of 
disturbances  of  respiration.  When  the  vocal  affection  is  the 
most  prominent  symptom,  the  disease  has  been  called  phonetic 
paralysis,  and  when  the  affection  of  respiration  predominates,  it 
has  been  called  respiratory  paralysis  ;^  when  there  is  marked 
disorder  of  both  functions,  the  disease  has  been  called  mixed 
laryngeal  paralysis. 

Paralysis  of  the  laryngeal  muscles  may  be  divided  into 
unilateral  or  bilateral  paralysis,   according  to  its  extent,   and 


'  SeeligmuUer.  "  Ein  Fall  von  Lahmung  des  Accessorius  Willisii."  Arch.  f. 
Psychiat.,  Bd.  III.,  1872,  p.  433. 

^  Woakes.  Paralysis  of  the  abductor  muscles  of  the  vocal  cord.  British 
MedicalJournal,  Vol.  II.,  1881,  p.  889. 

*  See  Riegel  (F.).  "  Respiratory  Paralyses,"  Volkmann's  collection  of  clinical 
lectures,  New  Syd.  Soc,  second  series,  1877,  p.  315;  and  "Ueber  die  Lahmung 
der  Glottiserweiterer,"  Berl.  klin.  Wochenschr.,  1872,  pp.  239  and  253. 


542 


DISEASES   OF   THE  MIXED   CRANIAL   NERVES. 


each  of  these  may  be  subdivided  into  total  or  partial  paralysis, 
according  to  its  degree. 

Phonetic  'paralysis  occurs  when  the  muscles  which  render 
tense  and  approximate  the  vocal  cords  are  paralysed,  and  the 
affection  of  voice  may  vary  from  slight  hoarseness  to  complete 
aphonia,  according  to  the  degree  and  extent  of  the  paralysis. 

Respiratory  paralysis,  on  the  other  hand,  occurs  when  the 
muscles  which  widen  the  aperture  of  the  glottis — the  crico- 
arytsenoidei  postici — are  paralysed.  In  such  cases  the  voice  is 
unaffected,  and  even  the  disturbance  of  respiration  may,  during 
rest,  be  so  slight  as  to  be  scarcely  perceptible,  although  difficulty 
of  respiration  is  readily  induced  on  slight  exertion;  at  other 
times  the  affection  gives  rise  to  the  most  alarming  inspiratory 
dyspncea. 

Mixed  paralysis  of  the  laryngeal  muscles  occurs  when  the 
recurrent  laryngeal  nerves  are  diseased ;  the  muscles  which 
dilate  the  glottis  and  those  which  render  tense  and  approximate 
the  vocal  cords  are  then  paralysed,  and  disorders  both  of  voice 
and  of  respiration  are  present. 

The  most  important  signs  of  paralysis  of  the  laryngeal  muscles 
are  observed  on  laryngoscopic  examination ;  and  as  the  vocal 
cords  are  placed  under  the  simplest  condition  in  the  mixed 
forms  of  paralysis,  we  shall  describe  these  first. 

Fig.  66. 


Fig.  66  (f  om  Landois'  "  Physiologie  "J.  Laryngoscopic  apptarances  of  the  interior  of 
Hielarynx. — L.,  The  root  of  1  he  tongue  ;  V.V.,  Glosso-epiglottidean  ligament; 
E.-,  The  epiglottis ;  B.,  Glottis ;  L.  v..  The  true  vocal  cord ;  S.  31.,  Opening  into 
the  sinus  of  Morgagni ;  L.  v.  s.,  The  false  vocal  cords  ;  S.  S.,  The  projection  of 
the  cartilages  of  Santorini ;  P.,  Pharynx  wall;  W,  W.,  The  cartilages  of 
Wrisberg  in  the  ary-epiglottidean  ligament;  S.  p..  The  sinus  piriformis. 


DISEASES   OF  THE  MIXED   CRANIAL   NERVES. 


)43 


Fig.  67. 


Mixed  Paralyses. — In  complete  bilateral  paralysis  of  the 
laryngeal  muscles  the  glottis  assumes  the  cadaveric  position,  and 
remains  immovable  and  unchanged  during  attempts  at  phona- 
tion.  The  relaxed  cords  are  drawn  somewhat  downwards  during 
inspiration,  and  pushed  slightly  upwards,  and  probably  slightly 
removed  from  one  another,  during  expiration;  but  these  slight 
movements  are  very  dififerent  from  the  active  movements  caused 
by  contracting  muscles. 

In  complete  bilateral  paralysis  the  interference  with  re- 
spiration may  be  so  slight  as  to 
escape  notice  during  quietude ; 
but  dyspnoea,  accompanied  by 
stertorous  or  stridulous  inspira- 
tion from  narrowing  of  the  glottis 
and  irregular  vibrations  of  the 
vocal  cords,  is  readily  induced 
on  slight  exertion.  From  the 
position  of  the  vocal  cords  it  is 
manifest  that  dyspnoea  will  be 
readily  induced  when  the  para- 
lysis is  complicated  by  a  slight 
catarrh.  The  voice  is  weak,  and 
may  be  reduced  to  an  almost 
inaudible  whisper. 

In  complete  unilateral  para- 
lysis of  the  laryngeal  muscles  the 
vocal  cord  of  the  corresponding 
side  is  motionless,  its  free  edge 
is  slightly  removed  from  the 
middle  line,  and  the  vocal  cord 
of  the  sound  side  alone  vibrates 
during  attempts  at  phonation. 
The  voice  may  be  completely  lost, 
but  more  frequently  it  is  harsh 
and  discordant,  and  is  liable  to 
break  into  falsetto  tones  on  the 
slightest  strain.^ 


Fig.  67.  Laryngoscopic  appearance  of 
the  larynx  during  quiet  breatJiing. 

Fig.  68. 


Fig.  68.  The  laryngoscopic  appearance 
of  the  larynx  during  vocalisation. 

Fig.  69. 


*  Mackerzie  (Morell).  A  manual  of 
diseases  of  the  throat  and  nose.  Lond., 
1880.     p.  447. 


Fig.  09.  The  lai  yngoscuj^itc  appeal  aace 
of  the  larynx  during  deep  inspira- 
tion, showing  the  bifurcation  of  the 
trachea. 


544  DISEASES   OF   THE   MIXED   CBANIAL   NERVES. 

In  incomplete  paralysis,  whether  unilateral  or  bilateral,  the 
power  of  excursion  of  the  vocal  cord  is  merely  diminished  and 
not  entirely  lost. 

Respiratory  Paralysis. — When  the  crico-aryteenoidei  postici 
are  paralysed,  the  vocal  cords  assume  the  cadaveric  position  just 
as  in  complete  paralysis  of  all  the  laryngeal  muscles.  In  isolated 
paralysis  of  the  abductors  of  the  larynx,  however,  the  approxi- 
mation and  parallelism  of  the  vocal  cords  can  still  be  accom- 
plished, and  the  voice  remains  unaffected,  but  the  glottis  does 
not  dilate  during  deep  inspiration,  and  the  cords  cannot  be 
separated  beyond  the  cadaveric  position.  The  respiratory  function 
is  at  first  only  slightly  interfered  with,  ■  in  a  way  exactly  corre- 
sponding to  that  which  has  been  described  as  occurring  in  com- 
plete paralysis  of  all  the  muscles.  In  complete  paralysis,  however, 
the  contractile  power  of  both  the  abductors  and  the  adductors  is 
abolished,  but  in  paralysis  of  the  crico-arytsenoidei  postici  the 
abductors  alone  are  paralysed,  while  the  adductors  remain  active. 
The  healthy  adductors  after  a  time  undergo  "  paralytic  con- 
traction," and  consequently  drag  the  vocal  cords  still  further 
towards  the  middle  line,  so  that  the  cadaveric  position  of  the 
cords  is  much  exceeded,  and  the  glottis  is  almost  completely 
closed.  The  glottis  is  now  converted  into  a  narrow  slit,^  and 
becomes  quite  inadequate  to  carry  on  ordinary  respiration. 

When  the  paralysis  is  complete,  the  adductor  muscles  soon 
contract  to  such  an  extent  as  to  give  rise  to  the  noisy  breathing 
characteristic  of  croup.  Owing  to  the  marked  constriction  of 
the  glottis  respiration  becomes  laborious,  the  accessory  muscles 
of  inspiration  are  brought  into  action  in  order  to  overcome  the 
obstruction,  inspiration  is  prolonged  and  noisy,  while  expiration 
is  comparatively  easy  and  quick ;  the  breathing  is  what  has  been 
described  as  the  "  forced  costal  type ;"  whilst,  in  consequence  of 
the  difference  of  atmospheric  pressure  above  and  below  the  con- 
stricted part,  the  larynx  moves  up  and  down  considerably  during 
each  respiratory  act. 

On  laryngeal  examination  it  is  seen  that  the  vocal  cords  are 
approximated  so  that  only  a  narrow  linear  chink  is  left  between 
them,    while   the   cords,   instead   of    separating   during   forced 

1  Riegel.  Zur  Lehre  von  den  Motilitatsnevirosen  des  Kehlkopfes.  Berl.  klin. 
Wochenschr.,  Bd.  XVIII.,  1881,  p.  737. 


DISEASES   OF  THE   MIXED   CRANIAL   NERVES.  545 

inspiration,  approach  each  other  so  closely  as  almost  completely 
to  close  the  glottis.  The  cords  are  separated  slightly  during  each 
expiratory  act.  During  intonation  the  vocal  cords  and  arytaenoid 
cartilages  approach  one  another  in  a  perfectly  normal  manner. 

Incomplete  bilateral  paralysis  may  exist  for  a  long  time  with- 
out giving  rise  to  difficulty  of  breathing.  It  is  probable  that  in 
many  such  cases  the  respiratory  troubles  continue  so  slight  that 
they  do  not  attract  attention,  and,  owing  to  the  entire  absence  of 
affection  of  voice,  the  patient  may  not  be  subjected  to  laryngo- 
scopic  examination,  and  the  disease  thus  not  detected.  The 
affection  also  does  not  give  rise  to  any  very  manifest  symptoms 
when  it  is  unilateral,  but  such  a  condition  could  doubtless  be 
detected  on  laryngoscopic  examination. 

Phonetic  Paralysis. — Paralysis  of  the  muscles  which  render 
tense  and  approximate  the  vocal  cords  gives  rise  to  disorders  of 
voice. 

(1)  In  bilateral  paralysis  of  the  adductors  the  glottis  is  par- 
tially open,  and  both  the  arytsenoid  cartilages  and  the  vocal  cords 
are  immovable  during  attempts  at  phonation  ;  the  latter  do  not 
vibrate,  and  the  glottis  cannot  be  closed  in  coughing,  on  making 
an  effort,  or  during  deglutition,  while  there  is  complete  aphonia. 

(2)  In  unilateral  paralysis  of  the  adductors  the  vocal  cord  of 
the  affected  side  is  removed  from  the  middle  line,  and  cannot  be 
approximated  to  its  fellow.  The  affected  vocal  cord  can  only 
vibrate  with  its  edge,  and  consequently  the  voice  is  feeble,  and 
readily  assumes  the  falsetto  character. 

(3)  Paralysis  of  the  crico-thyroid  muscles  occurs  when  the 
superior  laryngeal  nerve  is  implicated  in  disease,  either  directly 
or  through  the  spinal  accessory  nerve.  When  these  muscles  are 
paralysed  the  vocal  cords  cannot  be  rendered  tense,  and  conse- 
quently the  voice  becomes  hoarse  and  deep,  and  the  production 
of  high  notes  is  difficult  or  impossible.  Disease  of  the  superior 
laryngeal  nerve  also  paralyses  the  thyro-arytaeno-epiglottidei,  and 
the  epiglottis  is  consequently  drawn  towards  the  tongue,  so  that 
during  deglutition  it  is  not  depressed  over  the  aperture  of  the 
glottis,  hence  food  and  drink  obtain  entrance  into  the  larynx. 
Owing  to  the  accompanying  anaesthesia  the  reflex  act  of  coughing 
is  not  set  up  until  the  foreign  substance  passes  below  the  level  of 
the  vocal  cords,  and  thus  an  attack  of  pneumonia  is  likely  to  be 

VOL.  I.  J  J 


346  DISEASES   OF  THE  MIXED   CRANIAL   NERVES. 

provoked.  In  paralysis  of  the  tensors  of  the  vocal  cords  the 
glottis  closes  completely  during  strong  expiratory  efforts,  as  in 
coughiog,  and  the  aryta^noid  cartilages  are  quite  movable  during 
attempts  at  phonation.  The  absence  of  tension  of  the  crico- 
thyroid muscle  during  vocalisation  may  sometimes  be  perceived 
by  placing  the  finger  over  the  crico-thyroid  space.  When  the 
affection  is  bilateral,  the  glottis  is  represented  by  a  wavy  line, 
and  in  unilateral  paralysis  the  cord  on  the  affected  side  remains 
on  a  higher  level  than  its  fellow, 

(4)  In  paralysis  of  the  thyro-arytcenoidei  the  ligamentous 
part  of  the  glottis  remains  open,  while  juxtaposition  of  the 
arytsenoid  cartilages  takes  place. 

(5)  In  paralysis  of  the  orico-arytcenoidei  lateralis  the  glottis 
remains  open  in  the  form  of  a  tolerably  broad  ellipse. 

(6)  In  paralysis  of  the  arytmnoidei  the  ligamentous  portion 
closes  almost  completely,  while  the  interspace  between  the  ary- 
tsenoid cartilages  remains  open  in  the  form  of  a  triangular  space. 

Although  loss  of  voice  is  present  in  paralysis  of  all  the  tensor 
and  constrictor  muscles,  yet  it  is  most  marked  in  the  cases 
where  the  interspace  between  the  cartilages  remains  open,  while 
the  voice  may  be  very  little  affected  in  the  cases  where  the  car- 
tilages close  and  the  ligamentous  portion  remains  open.  Under 
the  former  circumstances  the  blast  of  air  escapes  through  the 
patent  glottis  respiratoria,  and  the  cords  are  not  set  in  vibration, 
but  under  the  latter  the  blast  of  air  must  pass  through  the 
glottis  vocalis,  and  a  certain  degree  of  vibration  of  the  cords  will 
be  caused.  A  case  has  been  reported  by  FraentzeP  in  which 
there  was  simultaneous  paralysis  ©f  the  adductors  and  spasm, 
probably  of  the  nature  of  paralytic  contraction,  of  the  abductors 
of  the  vocal  cords.  Every  form  of  vocalisation  was  lost,  and  even 
an  energetic  cough  was  toneless. 

In  peripheral  laryngeal  paralysis,  due  to  compression  or  injury 
to  the  recurrent  nerve,  the  muscles,  like  others  under  similar 
conditions,  become  atrophied  and  lose  their  farad  ic  and  galvanic 
contractility.  It  is  a  very  curious  circumstance  that  bilateral 
compression  of  the  recurrent  laryngeal  nerves  causes  by  pre- 
ference paralysis  of  the  abductors  of  the  vocal  cords  while  fre- 

'  Fraentzel.  Ein  Fall  von  Lahmung  der  Glottisverenger  mit  Spasmus  der 
Glottiserweiterer.    Charite-Ann.  (1879),  Berl.,  Bd.  VI.,  1881,  p.  271. 


DISEASES   OF   THE  MIXED   CRANIAL  NERVES.  547 

quently  leaving  the  adductors  unaffected.  Semon,^  who  first 
directed  special  attention  to  this  fact,  supposes  that  the  fibres 
which  supply  the  abductors  occupy  the  peripheral  portion  of  the 
nerve,  and  are  thus  the  first  to  be  subjected  to  pressure,  but  this 
explanation  is  not  generally  regarded  as  satisfactory.^ 

(7)  Rheumatic  laryngeal  paralysis  is,  as  a  rule,  unilateral, 
and  may  be  complete  or  incomplete;  occasionally  it  is  bilateral. 
When  the  paralysis  is  incomplete,  the  thyro-arytsenoidei  are 
affected  by  preference ;  and  in  paralysis  of  these  muscles,  as 
already  remarked,  the  ligamentous  portion  of  the  glottis  does 
not  close  completely.  Rheumatic  paralysis  is  frequently  asso- 
ciated with  catarrhal  conditions  of  the  larynx,  but  how  far  any 
causal  relation  obtains  between  them  is  not  known. 

(8)  Hysterical  ajphonia  appears  generally  to  result  from 
paralysis  of  the  arytasnoid  muscles,  and  thus  when  the  liga- 
mentous portion  of  the  glottis  closes,  the  interspace  between 
the  cartilages  remains  open.  This  form  of  aphonia  occurs  in 
paroxysms,  which  sometimes  come  on  at  regular  periods  of  the 
day,  and  during  the  interval  the  laryngoscopic  appearances  are 
quite  normal. 

The  Diagnosis  is  based  chiefly  upon  the  appearances  presented 
by  the  glottis  on  laryngoscopic  examination,  although  valuable 
confirmatory  evidence  is  afforded  by  the  general  symptoms. 

The  Prognosis  depends  upon  the  nature  of  the  cause.  It  is 
most  favourable  in  hysterical  and  rheumatic  paralysis,  and  in 
that  which  occurs  after  severe  exertion  of  the  voice,  and  as  a 
sequel  of  acute  infections  diseases.  When  the  paralysis  is  caused 
by  compression  or  injury  of  the  nerve,  the  prognosis  is  unfavour- 
able, and  it  is  equally  unfavourable  in  paralysis  of  organic 
disease  of  the  nerve  centres. 

Treatment. — The  treatment  must  vary  according  to  the  cause 
of  the  affection,  and  in  severe  cases  of  laryngeal  paralysis,  due 
to  compression  of  the  recurrent  nerves  by  aneurisms  and  other 
tumours,  the  treatment  must  be  directed  to  the  primary  disease, 
and  this,  unfortunately,  is  in  most  cases  of  very  little  avail  so 

'  Semon  (Felix),  Clinical  Society's  Transactions,  Vol,  XI.,  1878,  p.  141 ;  and 
Vol.  XII.,  1879. 

'  See  Lefferts  (G.  M.).  "  Laryngoscopic  signs  in  connection  with  injuries  or 
diseases  of  the  motor  nerves  of  the  larynx."  Transactions  of  the  International 
Medical  Congress,  Vol  III.,  Lond.,  1881,  p.  215. 


548  DISEASES   OF   THE   MIXED   CRANIAL   NERVES, 

far  as  the  laryngeal  symptoms  are  concerned.  In  most  cases  of 
laryngeal  paralysis  the  best  direct  treatment  consists  in  the 
local  application  of  the  faradic  current.  One  of  the  electrodes 
may  be  passed  by  the  aid  of  the  laryngoscope  into  the  larynx, 
while  the  other  is  placed  on  some  part  of  the  surface.  The 
instruments  devised  by  Duchenne  and  by  Morell  Mackenzie 
answer  very  well  for  the  purpose,  but  this  method  of  applica- 
tion is  somewhat  troublesome,  and  requires  a  certain  amount  of 
special  skill  not  possessed  by  the  majority  of  physicians.  Except 
in  very  obstinate  cases  the  percutaneous  application  of  the 
faradic  or  galvanic  currents  is  amply  sufficient,  so  that  the 
trouble  of  passing  the  electrode  into  the  larynx  is  avoided.  In 
hysterical  aphonia,  indeed,  the  application  of  the  faradic  brush 
over  the  surface  of  the  larynx,  so  as  to  cause  pain,  is  probably 
more  efficacious  than  even  intralaryngeal  faradisation. 

The  subcutaneous  injection  of  strychnia  has  been  found  useful 
by  Waldenburg  and  others  in  rheumatic  and  catarrhal  laryngeal 
paralysis,  and  in  that  occurring  after  diphtheria. 

(C)  Diseases  of  the  Trunk  of  the  Vagus  and  of  the  Pulmonary, 
Gastric,  and  Cardiac  Plexuses. 

(1)  Diseases  of  the  Trunk  of  the  Vagus. 

§  277.  The  trunk  of  the  vagus  is  liable  to  be  injured  by  various 
causes,  such  as  gunshot  wounds,  and  surgical  operations  for  the 
extirpation  of  tumours  or  for  ligature  of  the  carotid  artery ;  it 
may  also  undergo  compression  from  enlarged  lymphatic  glands, 
tumours  and  abscesses  in  the  neck,  and  aneurisms  of  the  larger 
arterial  trunks  in  the  chest  and  neck. 

In  the  majority  of  cases  the  injury  is  limited  to  one  side,  and 
may  occur  either  above  or  below  the  point  of  origin  of  the 
recurrent  laryngeal.  The  symptoms  correspond  generally  to 
those  observed  in  the  lower  animals  after  experimental  injury. 
When  the  phenomena  of  irritation  predominate,  the  action  of 
the  heart  is  rendered  slow  and  irregular,  and  the  symptoms  of 
angina  may  be  present. 

More  frequently,  however,  the  symptoms  are  those  of  paralysis 
of  the  vagus.  Passing  over  the  symptoms  of  laryngeal  paralysis, 
which  have  been  described  already,  paralysis  of  the  vagus,  either 


DISEASES   OF  THE  MIXED   CRANIAL   NERVES,  549 

unilateral  or  bilateral,  causes  increase  in  the  frequency  of  the 
pulse,  which  may  beat  permanently  at  the  rate  of  160,  or  in 
some  cases  as  high  as  200^  or  224^  per  minute.  The  radial  pulse 
becomes  small  and  scarcely  perceptible,  and  the  arterial  tension 
is  diminished. 

The  alteration  of  the  pulse  is  a  striking  symptom  of  slow 
growing  mediastinal  tumours,  and  may,  indeed,  for  a  long  time 
be  the  only  symptom  by  which  the  presence  of  the  tumour  can 
be  suspected.  In  such  cases  the  action  of  the  heart  does  not 
appear  to  be  rendered  slow  by  the  use  of  digitalis.  In  the 
majority  of  cases  the  symptoms  caused  by  mechanical  com- 
pression of  the  lungs  and  surrounding  textures  are  present,  and 
then  the  diagnosis  is  much  facilitated.  In  compression  of  the 
vagus  by  tumours,  death  may  result  from  syncope  caused  by  irri- 
tation of  the  inhibitory  fibres  of  the  vagus. 

(2)  Diseases  op  the  Pulmonary  Plexus. 

The  innervation  of  the  respiratory  mechanism  has  already 
been  described  (§  97),  as  well  as  the  chief  disorders  to  which  it 
is  liable.  It  only  remains  for  us  at  present  to  allude  briefly  to 
the  chief  pulmonary  affections  caused  by  direct  or  indirect  irrita- 
tion of  the  fibres  which  are  distributed  to  the  lungs  through  the 
pneumogastric  nerves. 

Asthma  hronchiale  seu  nervosuvi. 

§  278.  Nervous  asthma  consists  of  paroxysmal  attacks  of  diffi- 
culty of  breathing  caused  by  general  contraction  of  the  smaller 
bronchial  tubes. 

Etiology. — Asthma  is  often  inherited,  and  frequently  descends 
directly  from  parents  to  children.  One  member  of  a  family 
may  suffer  from  asthma,  while  others  suffer  from  epilepsy  and 
allied  affections.  Males  are  twice  as  frequently  affected  as 
females.  The  first  attack  generally  occurs  prior  to  the  age  of 
ten,  although  it  may  appear  at  any  age  from  birth  to  extreme 
old  age. 

The  exciting  causes  may  be  direct  or  indirect.     The  direct 

'  "Weil.     Deutsches  Arch,  fiir  klin.  Med.,  Bd.  XIV.,  1874,  p.  89. 
^  von    Huppert.       "  Eeine    Motilitiits    neurose    des    HerzeBS."      Berl.    klin. 
Wochensclir.,  1874,  p.  223. 


550  DISEASES  OF  THE  MIXED   CRANIAL  NERVES. 

causes  act  on  the  mucous  membrane  of  the  bronchial  tubes. 
The  most  usual  of  these  are  the  inhalatioD  of  smoke,  dust,  or 
irritating  gases;  the  smell  of  cats,  dogs,  horses,  or  other  animals; 
the  scent  of  the  privet,  rose,  and  other  flowers ;  and  the  emanations 
from  new-mown  hay  and  powdered  ipecacuanha.  Change  of 
locality  has  a  very  curious  influence  on  the  disease.  Some 
asthmatics  can  live  a  comfortable  life  in  the  most  crowded 
thoroughfares  of  towns,  who  are  subject  to  severe  paroxysms 
of  dyspnoea  in  pure  country  air.^  Some  suffer  most  in  high 
altitudes,  others  at  a  low  elevation,  some  in  dry,  others  in  a 
moist  atmosphere,  and  some  can  live  with  tolerable  comfort  on 
one  side  of  a  street  and  suffer  greatly  on  the  opposite  side.  I 
have  known  a  boy  four  years  of  age  who  had  his  first  attack  on 
being  transferred  from  London  to  a  country  village  in  Yorkshire, 
far  removed  from  the  smoke  of  factories.  He  had  a  severe 
paroxysm  on  each  of  three  consecutive  nights  in  which  he  slept 
in  one  bedroom ;  but  on  being  transferred  on  the  third  night  to 
an  adjoining  bedroom  the  paroxysm  ceased,  and  he  had  only  one 
attack  during  the  following  six  months.  On  this  occasion  he 
was  sent  to  sleep  in  the  first  bedroom,  but  a  severe  paroxysm 
soon  developing  he  was  obliged  to  be  removed,  when  the 
dyspnoea  immediately  ceased. 

The  indirect  causes  are  certain  articles  of  diet,  which  differ 
almost  for  each  patient,  distention  of  the  stomach,  constipation, 
and  violent  emotions. 

SyTYiptoms. — The  asthmatic  attack  is  often  preceded  by 
certain  premonitory  symptoms,  which  vary  in  different  cases. 
The  most  usual  symptom  consists  of  a  feeling  of  constriction 
across  the  chest  with  a  slight  tendency  to  wheeze,  but  at  times 
it  consists  of  flatulence,  depression,  or  even  unusual  buoyancy  of 
spirits.  One  asthmatic  patient  told  me  that  he  knew  a  severe 
attack  was  about  to  begin  when  he  passed  an  abundant  quantity 
of  clear  limpid  urine.  The  symptoms  of  the  paroxysm  are  those 
of  intense  dyspnoea,  and  they  are  usually  well  described  in  works 
devoted  to  diseases  of  the  chest,  so  that  it  is  unnecessary  to 
describe  them  in  detail  in  this  place.  The  patient  is  probably 
roused  at  from  two  to  four  o'clock  in  the  morning  with  an  intense 

1  Watson  T.).  Lectures  on  the  principles  and  practice  of  physic.  4th  Edit., 
1857.    Vol.  II.,  p.  361. 


DISEASES   OF  THE  MIXED   CRANIAL   NERVES.  551 

feeling  of  suffocation.  During  the  paroxysm  the  breathing  is 
slow  and  laboured  and  effected  with  the  most  violent  effort. 
The  patient  sits  with  head  thrown  back,  dilated  nostrils,  and 
mouth  widely  open]  he  generally  grasps  some  fixed  object  so  as^ 
to  give  him  increased  purchase,  and  the  accessory  muscles  of 
inspiration  are  thrown  into  energetic  action.  The  expression  is 
one  of  deep  anxiety ;  the  surface  is  pale  and  ghastly ;  the  hands 
and  feet  are  cold  and  livid ;  the  body  is  bathed  in  sweat ;  the 
eyes  are  congested  and  protruding  ;  and  the  pulse  is  small,  feeble, 
and  often  irregular.  The  lungs  become  expanded  and  hyper- 
resonant  on  percussion;  the  diaphragm  is  depressed,  and  con- 
sequently the  liver  and  spleen  are  displaced  downwards ;  the 
normal  respiratory  murmur  is  found  on  auscultation  to  be 
replaced  by  loud  sibilant  ronchi;  and  towards  the  end  of  the 
attack  the  patient  often  expectorates  a  considerable  quantity  of 
frothy  and  sometimes  sanguinolent  mucus. 

The  duration  of  a  single  paroxysm  is  comparatively  brief,  but 
a  series  of  them  may  extend  over  some  weeks. 

Cases  of  asthma  have  been  described  in  which  the  respiratory 
symptoms  were  associated  with  great  acceleration  of  the  pulse. 
In  a  case  under  the  care  of  Prof  Riegel  and  reported  by  Tuczek,^ 
the  pulse,  which  was  of  normal  frequency  immediately  before  and 
after  the  attack,  beat,  as  often  as  from  198  to  208  in  a  minute,^ 
while  the  respiratory  difficulties,  although  well  marked,  were  by 
no  means  excessive.  In  a  case  recently  communicated  by  KredeP 
there  was  urgent  dyspnoea  during  the  attack ;  the  breathing  was 
of  the  upper  costal  type  ;  the  respirations  were  as  high  as  fifty- 
two  in  a  minute  ;  the  face  was  cyanotic  ;  the  lungs  were  greatly 
distended ;  the  patient  complained  of  a  feeling  of  oppression ; 
and  the  pulse  beat  from  132  to  148  in  the  minute.  This  patient 
had  suffered  from  an  attack  of  acute  rheumatism,  and  a  loud  sys- 
tolic murmur  was  heard  over  the  apex  of  the  heart.  He  also  had 
a  large  goitre,  which  was  swollen  and  tender  during  the  attack. 

Prognosis. — So  far  as  any  immediate  danger  to  life  is  con- 
cerned the  prognosis  is  favourable  ;  but  as  a  rule  the  paroxysms 


'  Tuezek  (Fr.).  "Ueber  Vaguslahmung."  Deutsches  Arch.  f.  klin.  Med., 
B(i.  XXI.,  1878,  p.  102. 

^  Kredel.  "  Zur  Lelire  von  den  Vagusneurosen."  Deutsches  Arch.  f.  klin. 
Med.,  Bd.  XXX.,  1882,  p.  547. 


552  DISEASES  OF  THE  MIXED  CRANIAL  NERVES. 

recur  at  regular  intervals  of  time  during  the  remainder  of  life. 
When  the  disease  begins  in  infancy  it  often  disappears  during 
the  adult  period  of  life,  but  when  it  comes  on  late  in  life  it  is 
usually  permanent. 

Morbid  Physiology. — The  symptoms  are  mainly  caused  by 
spasmodic  contraction  of  the  muscular  tissue  of  the  bronchial 
tubes.  The  expectoration  of  frothy  mucus  which  generally 
accompanies  an  attack  would  seem  to  indicate  that  the  symp- 
toms are  also  in  part  caused  by  an  oedematous  swelling  of  the 
mucous  membrane  of  the  smaller  bronchi.  Those  who  are  sub- 
ject to  nasal  catarrh  will  readily  understand  the  suddenness  with 
which  such  a  swelling  may  appear,  and  the  amount  of  obstruc- 
tion and  discomfort  to  which  it  may  give  rise.  The  asthmatic 
paroxysm  may  be  excited  by  direct  irritation  of  the  trunk  of 
the  vagus ;  in  other  cases  it  is  caused  by  reflex  irritation  of  the 
sensory  nerves  of  the  lungs  themselves,  or  of  those  of  remote 
organs,  such  as  the  stomach,  intestines,  or  uterus.  An  attack 
sometimes  results  from  central  irritation,  and  it  is  then  generally 
associated  with  hysteria.  The  recorded  cases  of  combined  asth- 
matic paroxysms  and  great  acceleration  of  pulse  would  appear  to 
require  for  their  explanation  a  simultaneous  irritation  of  the 
pulmonary  and  paralysis  of  the  cardio-inhibitory  fibres  of  the 
vagus.  The  number  of  these  eases  recorded  are  at  present  too 
few  to  reader  a  discussion  of  them  profitable. 

Treatment. — The  treatment  during  the  attack  must  be 
directed  to  allay  the  distressing  symptoms.  All  the  exciting 
causes,  whether  acting  directly  on  the  bronchi,  or  indirectly 
through  the  stomach  uterus  or  other  organs,  must,  if  possible, 
be  removed.  The  most  useful  direct  remedies  during  the  attack 
are  tartar  emetic,  and  ipecacuanha  in  emetic  doses,  while  tobacco, 
lobelia  inflata,  datura  strammonium  or  datura  tatula  may  be 
used  as  cigarettes,  or  in  the  form  of  tincture  or  extract.  Bella- 
donna, conium,  or  hyoscyamns  may  be  given  in  strong  coffee ; 
brandy  or  whisky  with  hot  water,  and  nitre  paper  burnt  in  the 
apartment,  are  useful  and  often  convenient  remedies;  but  in 
severe  paroxysms  the  greatest  relief  is  obtained  from  the  in- 
halation of  chloroform  or  ether. 

In  the  interval  between  the  attacks  care  must  be  taken  to 
avoid  all  the  exciting  causes  of  the  affection.     The  patient  must 


DISEASES   OF   THE   MIXED   CRANIAL   NERVES.  558 

be  allowed  to  select  his  own  residence,  as  it  is  not  possible 
beforehand  to  tell  what  kind  of  air  and  climate  will  suit  him 
best.  The  greatest  care  must  be  taken  in  preventing  the  surface 
of  the  body  from  being  chilled  by  wearing  flannel  next  the  skin, 
whilst  the  diet  must  be  carefully  regulated, 

(3)  Diseases  of  the  Gastric  Plexus. 

§  279.  Some  of  the  sensory  neuroses  of  the  gastric  plexus, 
such  as  pyrosis,  bulimia,  polydipsia,  and  polyphagia,  have 
already  been  considered  (§§  63  and  64) ;  it  remains  for  us  at 
present  to  describe  the  chief  affections  caused  by  direct  or  in- 
direct irritation  of  the  fibres  of  the  pneumogastric  nerves  which 
are  supplied  to  the  gastric  plexus.  These  are  (a)  vomiting,  and 
(b)  tabetic  gastric  crises, 

(a)  Vomiting. — The  ejection  of  the  contents  of  the  stomach 
through  the  mouth  is  caused,  not  so  much  by  an  active  con- 
traction of  the  stomach  itself,  as  by  the  compression  of  the 
organ  produced  by  contraction  of  the  diaphragm  and  abdominal 
muscles.  Before  vomiting  can  occur,  however,  there  must  be  an 
active  opening  of  the  cardiac  orifice  of  the  stomach,  which  is 
most  probably  produced  through  the  medium  of  the  pneumo- 
gastric nerves.  The  vomiting  which  results  from  disorders  of 
the  nervous  mechanism  of  the  stomach  may  be  caused  by  reflex 
or  central  irritation.  Reflex  vomiting  may  be  caused  by  irri- 
tating matter  in  the  stomach  itself,  or  by  irritation  of  remote 
organs  such  as  the  fauces,  intestines,  and  uterus.  The  central 
causes  of  vomiting  are  organic  diseases  of  the  brain  and  its 
membranes,  anaemia  and  hypergemia  of  the  brain,  shock, 
hysteria,  and  certain  poisons,  such  as  nicotine,  opium,  and  effete 
constituents  circulating  in  the  blood  in  various  diseases.  The 
depressing  emotions,  and  disgust,  whether  excited  through  the 
senses  or  imagination,  often  excite  vomiting.  Vomiting  is  a 
prominent  symptom  of  all  disorders  of  the  mechanisms  which 
adjust  the  body  to  surrounding  objects  in  space,  the  chief  of 
these  being  Meniere's  disease,  cerebellar  affections,  and  disturb- 
ances of  the  oculo- motor  neuro- muscular  mechanism.  When 
objects  are  undergoing  rapid  and  unusual  displacements  with 
reference  to  the  organism,  such  as  occur  on  board  ship,  sickness 
and  vomiting  are  apt  to  be  induced.    The  vomiting  which,  occurs 


554  DISEASES   OF  THE  MIXED   CRANIAL  NERVES. 

ia  certain  cases  of  locomotor  ataxia  is  so  peculiar  and  charac- 
teristic as  to  deserve  separate  description. 

(b)  Tabetic  Gastric  Crises. — The  attack  of  vomiting  is  preceded 
by  severe  gastralgia,  which  begins  suddenly  during  a  paroxysm 
of  lancinating  pains.  The  patient  complains  of  pain  which 
starts  from  the  groins,  passes  up  each  side  of  the  abdomen,  and 
becomes  fixed  in  the  epigastrium,^  while  at  the  same  time  severe 
lightning  pains  dart  from  between  the  shoulders  and  radiate 
round  the  base  of  the  thorax.  Severe  vomiting  now  sets  in ;  the 
food  in  the  stomach  is  first  rejected,  then  everything,  whether 
liquid  or  solid,  which  the  patient  swallows,  and  finally  a  quantity 
of  watery  mucus,  which  is  at  first  colourless,  but  may  ultimately 
become  mixed  with  bile  and  blood.  The  patient  suffers  during 
the  attack  from  vertigo  and  a  profound  malaise ;  the  action  of 
the  heart  is  accelerated  ;  and  the  lightning  pains  are  unusually 
severe.  The  attack  may  last  without  respite  for  two  or  three 
days,  and  may  recur  every  two  or  three  weeks,  although  the 
usual  interval  between  them  is  not  less  than  a  month.  The 
gastralgic  attacks  are  most  probably  caused,  as  first  suggested 
by  Buzzard,^  by  irritation  resulting  from  sclerosis  in  the  neigh- 
bourhood of  the  nucleus  of  the  vagus.  Neuralgia  of  the  gastric 
plexus  will  be  considered  along  with  the  diseases  of  the  sym- 
pathetic system  of  nerves. 

(4)  Diseases  of  the  Cardiac  Plexus. 

The  part  which  the  vagus  takes  in  the  neuroses  of  the  cardiac 
plexuses  cannot  as  yet  be  separated  from  the  action  of  the  sym- 
pathetic ;  hence  it  will  be  as  well  to  deal  with  the  affections  of 
this  plexus  when  the  diseases  of  the  sympathetic  system  of 
nerves  are  under  consideration. 

(III.)-DISEASES   OF   THE   SPINAL   ACCESSORY   NERVE. 

The  spinal  accessory  nerve  subdivides  into  two  branches — an 
external  derived  from  the  spinal  cord,  and  an  internal  branch 
derived  from  the  medulla  oblongata.     The  external  branch  is 

1  See  Charcot  (J.  M.).  Legons  sur  les  maladies  du  systeme  nerveux.  Tome  II., 
1877,  p.  S3. 

-  See  Buzzard  (T.).  Clinical  lectures  on  diseases  of  the  nervous  system.  1882. 
p.  194. 


DISEASES   OF   THE   MIXED   CRANIAL   NERVES.  000 

distributed  to  the  sterno-cleido-mastoid  and  trapezius  muscles, 
which  receive  branches  also  from  the  cervical  plexus ;  the 
internal  branch  blends  with  the  trunk  of  the  pneumogastric 
nerve,  and  supplies  the  muscles  of  the  larynx  through  the 
recurrent  laryngeal  nerve.  The  spinal  accessory  being  a  purely 
motor  nerve,  its  diseases  ought  probably  to  have  been  described 
in  the  preceding  chapter ;  but  inasmuch  as  it  belongs  to  what 
Meynert  calls  the  "  mixed  lateral  system "  of  nerves,  and  is 
closely  related  anatomically  to  the  vagus,  I  have  determined  to 
place  the  affections  of  this  nerve  amongst  those  of  the  mixed 
cranial  nerves. 

The  diseases  of  the  external  branch  of  the  nerve  alone  remain 
to  be  considered  ;  they  may  be  divided  into  (1)  spasm,  and  (2) 
paralysis  of  the  muscles  supplied  by  it. 

(Ij  Spasm  in  tJie  Region  of  the  External  Branch  of  the  Spinal 
Accessory.    Wry-neck  (Caput  Ohstipum  Spasticuni). 

§  280.  Etiology. — The  causes  of  the  disease  are  often  obscure. 
It  may  come  on  suddenly  during  the  night,  and  without  any 
assignable  cause ;  but  more  commonly  the  onset  is  gradual,  and 
often  so  insidious  that  the  real  nature  of  the  malady  is  at  first 
overlooked.  Brodie  mentions  the  case  of  a  woman  in  whom  the 
spasmodic  affection  alternated  with  insanity.  The  relatives  of 
those  suffering  from  wry -neck  are  not  unfrequently  subject  to 
hysteria  and  other  nervous  affections. 

The  male  sex  is  rather  more  frequently  affected  than  the 
female,  and  the  disease  is  generally  an  affection  of  adult  life. 
The  most  usual  exciting  causes  are  excessive  exertion,  violent 
emotions,  exposure  to  cold,  drunkenness,  and  poverty.  It  may 
be  caused  by  reflex  irritation  of  remote  organs,  such  as  the 
intestinal  canal  and  uterus. 

Symptoms. — Spasm  in  the  area  of  distribution  of  the  external 
branch  of  the  spinal  accessory  nerve  may  be  divided  into  (a) 
tonic,  and  (h)  clonic  wry-neck. 

(a)  The  tonic  form  (caput  obstipum  spasticum)  is  almost  ex- 
clusively confined  to  one  of  the  sterno-cleido-mastoid  muscles, 
but  a  part  of  the  trapezius  is  sometimes  affected.  This  form  of  the 
disease  being  always  unilateral  the  contracted  muscle,  from  the 


556 


DISEASES    OF   THE   MIXED    CRANIAL   NERVES. 


obliquity  of  its  direction,  rotates  the  head  so  that  the  occiput  is 
approximated  to  the  shoulder  of  the  affected  side ;  the  ear  of 
the  same  side  is  drawn  towards  the  clavicle ;  and  the  chin  is 
turned  upwards  and  towards  the  opposite  side.  In  chronic  cases 
the  cervical  region  of  the  vertebral  column  becomes  the  seat  of 
permanent  curvature,  the  convexity  of  which  is  directed  to  the 
sound  side,  while  there  is  a  compensatory  curve  in  the  dorsal 
and  lumbar  regions.  When  the  trapezius  alone  is  the  seat  of 
spasm  the  head  is  drawn  strongly  backwards  and  inclined  to 
the  affected  side ;  there  is  no  turning  of  the  chin  ;  the  point 
of  the  shoulder  is  elevated  ;  and  on  any  attempt  being  made 
to  bend  the  head  forwards  the  muscle  becomes  tense  and 
painful. 

(&)  The  clonic  form  of  spasm  of  the  muscles  of  the  neck 
may  be  either  unilateral  or  bilateral.  Sometimes,  indeed,  the 
unilateral  variety  invades  both  sides,  but  in  such  a  case  the 
muscles  on  each  side  contract  alternately  or  quite  irregularly ; 
while  in  the  true  bilateral  variety  the  affected  muscles  on  both 
sides  act  in  concert. 

The  disease  generally  begins  with  uneasiness  in  the  neck. 

Fig.  70. 


Fig.  70  Jrom  Duchenne).    Spasm  of  the  Trapezius. 


DISEASES   OF  THE   MIXED   CRANIAL   NERVES.  557 

extending  from  the  back  of  the  neck  or  the  occiput  to  one  of 
the  shoulders.     It  is  soon  noticed  by  the  patient  or  his  friends 
that  the  head  is  not  straight,  and  as  the  disease  advances  the 
uneasiness  amounts  to  pain,  which  may  occasionally  be  very 
severe,  but  is  generally  of  a  dull  aching  character,  and  has  its 
seat  in  the  course  of  or  at  the  insertion  of  the  muscle.    The  move- 
ments of  the  head  depend  of  course  upon  the  muscles  attacked ; 
in  the  usual   variety,   where   one  of  the  sterno-cleido-mastoid 
muscles  is  affected,  it   is  rotated  obliquely  to  one  side  by  a 
succession  of  jerks  in  such  a  manner  that  the  occiput  is  turned 
towards  the  shoulder  and  depressed,  while  the  chin  is  elevated 
in  the  opposite  direction.     The  muscle  on  the  side  to  which  the 
head  is  drawn  down  is  found  hard  and  contracted,  and  frequently  , 
hypertrophied.      When  the  trapezius  is  affected,  the  head  is 
bent   back   and   the   shoulder   raised   in   the   manner    already 
described.     At  the  end  of  a  short  time,  generally  a  few  seconds, 
the  muscle  relaxes  and  the  head  returns  to  the  normal  position, 
but  this  is  soon  followed  by  a  second  contraction  and  a  second 
rotation.     In  the  beginning  of  the  disease  there  is  a  considerable 
interval  between  each  contraction,  but  as  it  advances  this  interval 
is    so    shortened    that    there    may   be    twenty-two^    or   thirty^ 
contractions  in  the  minute.      Rombers^  counted  eleven  oscil- 
lations  of  the  head  in  fifteen  seconds  in  a  young  girl  affected 
by  the  disease.     In  an  early  stage  of  the  affection  the  patient 
may  arrest  the  spasm  by  a  voluntary  effort,  and  Bell  mentions  a 
case  where  the  patient,  when  the  paroxysm  was  at  its  worst,  was 
able  to  relax  the  muscle  for  a  short  time  by  a  voluntary  effort. 
The  spasm  may  also  be  arrested  by  fixing  the  head  and  neck ; 
with  this  view  the  patient  frequently  supports  the  head  with 
both  hands  or  places  it  against  a  resisting  object,  and  it  may 
also  cease  if  the  attention  be  strongly  attracted.     The  spasms 
are  increased  by  everything  that  lowers  the  general  health,  by 
physical  exertion,  and  by  emotional  excitement;  the  effect  of 
the  last  of  these  is  rendered  apparent  by  an  aggravation  of  the 
spasm  when  the  patient  is  subjected  to  examination. 

'  Bell  (C).  The  nervous  system  of  the  human  body.  Lond.,  J830.  Appendix 
CXLII. 

*  Hasse.  Virchow's  Handbuch  der  speciellen  Path,  and  Therap,  Bd.  IV., 
Abth.  I.,  1855,  p.  140. 

^  Romberg.    A  manual  of  the  nervous  diseases  of  man.     Vol.  I.,  1853,  p.  317. 


558  DISEASES   OF  THE  MIXED  CRANIAL   NERVES. 

In  a  case  of  moderate  intensity  the  patient  is  able  to  counter- 
act the  spasm  by  a  voluntary  contraction  of  the  muscles  of  the 
opposite  side ;  from  the  continual  antagonism  of  the  involuntary 
and  voluntary  actions  during  waking  hours,  the  head  presents  a 
series  of  oscillations,  in  which  the  chin  is  deviated  to  the  opposite 
side  by  the  former,  and  immediately  drawn  back  to  the  middle 
line  by  the  latter,  so  that  the  head  on  the  whole  is  maintained 
in  a  central  position.  But  when  the  disease  has  lasted  for  a 
longer  period,  the  voluntary  is  overpowered  by  the  spasmodic 
action,  so  that  the  patient  cannot  (without  extraneous  aid,  as  by 
pulling  it  with  the  hands)  bring  the  head  into  a  central  position, 
and  it  is  consequently  habitually  twisted  to  one  side.  Even 
.under  these  circumstances  the  patient  may  by  a  strong  voluntary 
eflfort  bring  the  chin  to  the  middle  line,  but  the  effort  causes 
distress,  and  cannot  be  maintained. 

Patients  are  distressed  by  wakefulness,  aggravated  by  the 
spasmodic  movements  of  the  head  against  the  pillow ;  but  when 
sleep  is  coming  on  they  usually  feel  the  movements  becoming 
gradually  less  and  less,  and  the  spasm  ceases  entirely  during 
sleep. -^  This  rule,  however,  is  not  without  its  exceptions,  since 
BelP  mentions  the  case  of  a  patient  who  had  perpetual  rolling  of 
the  head  both  night  and  day. 

The  disease  is  very  rarely  confined  to  the  muscles  supplied  by 
the  spinal  accessory  nerve ;  indeed,  there  is  some  reason  to 
believe  that  the  deeply-seated  muscles  at  the  back  of  the  neck — 
the  splenii  and  obliqui  capitis — which  receive  their  motor  power 
from  the  superior  cervical  nerve,  are  frequently  the  first  to  be 
affected,  and  they  are  at  least  generally  implicated.  When  the 
scaleni  are  affected,  Romberg  has  observed  anaesthesia  and  oedema 
of  the  corresponding  arm  caused  by  compression  of  the  brachial 
plexus  and  veins.  The  facial  nerve  is  frequently  involved,  and 
the  face  is  then  variously  distorted ;  the  motor  branch  of  the 
trigeminus  may  likewise  be  implicated,  and  the  patient  suffers 
from  masticatory  spasm;  and  in  severe  cases  the  disease  extends 
to  the  cervical  nerves  and  to  the  brachial  plexus,  and  then  the 
affection  is  characterised  by  various  spasmodic  movements  of 

'Reynolds  (J,  Russell).  Art.  "Torticollis."  Reynolds'  system  of  medicine. 
Vol.  II.,  1868,  p.  776. 

■^  Bell.     Op.  cit.,  Appendix  CXLIL,  Case  LXXV. 


DISEASES  OF  THE  MIXED  CRANIAL  NERVES.  559 

the  shoulder,  arm,  hand,  and  fingers,  which  have  a  strong 
resemblance  to  the  irregular  movements  of  chorea.  Two  cases 
came  under  my  notice  in  which  spasmodic  action  of  the  muscles 
of  the  face  and  neck  was  associated  with  spasm  of  some  of  the 
intercostal  muscles  of  the  same  side,  the  action  of  the  latter 
being  specially  apparent  in  the  axillary  regioa ;  and  Bell  says 
of  a  patient,  "  while  these  very  severe  fits  last,  which  is  for  about 
a  minute  each  time,  his  breathing  is  performed  with  difficulty, 
and  he  gasps  as  if  he  were  suffocating."  In  very  violent  cases 
the  disease  extends  even  to  the  muscles  of  the  lower  extremities, 
so  that,  as  BelP  remarks,  "the  whole  body  partakes  of  the 
tremor."  Occasionally  difficulty  of  deglutition  and  huskiness  of 
voice  have  been  noticed  as  symptoms,  owing  no  doubt  to  the 
extension  of  the  spasm  to  the  muscles  respectively  concerned  in 
those  functions.  The  clonic  form  of  the  disease,  when  limited 
to  the  spinal  accessory  nerve,  is  usually  confined  to  the  one  side 
of  the  body,  but  occasionally  both  sides  are  affected.  When 
the  two  sterno-cleido-mastoids  are  implicated,  the  head  is  rotated 
first  to  the  one  side  and  after  a  time  to  the  other,  according  as 
the  action  of  the  one  or  of  the  other  predominates  ;  occasionally 
the  two  may  happen  to  contract  simultaneously,  in  which  case 
the  head  is  bent  forwards  and  the  chin  is  drawn  to  the  sternum. 
The  faradic  irritability  of  the  affected  muscles  appears  to  be 
increased,  and  an  interrupted  current,  which  causes  no  pain  on 
the  healthy  side,  may  cause  great  pain  when  passed  through 
the  affected  muscles.  When  a  constant  current  of  moderate 
intensity  is  passed  through  the  contracting  muscles  the  spasm 
relaxes,  but  it  returns  immediately,  or  soon  afterwards,  when 
the  current  is  withdrawn. 

Points  of  arrest  are  frequently  observed  in  the  course  of  the 
nerve  or  over  the  affected  muscles. 

The  bilateral  clonic  variety  (Eclampsia  nutans — Salaam 
convulsion)  is  almost  exclusively  confined  to  children  from  the 
first  period  of  dentition  to  puberty.  The  disease  comes  on  in 
paroxysms,  each  of  which  lasts  only  from  a  few  seconds  to  some 
minutes,  but  generally  recurs  once  or  two  or  three  times  in  the 
course  of  the  day.  Sometimes,  however,  there  may  be  as  many 
as  six  or  ten  attacks  in  an  hour,  while  at  other  times  several 

^  Bell.     Op.  cit..  Appendix  CLI. 


560  DISEASES   OF  THE  MIXED   CRANIAL   NERVES, 

days  may  intervene  between  them.  During  the  attack  the  body 
and  head  are  bent  slightly  forward,  and  this  is  followed  by  almost 
instantaneous  relaxation,  to  be  succeeded  after  an  interval  of  a 
few  seconds  by  a  second  bowing  of  the  head,  and  so  on  until  the 
paroxysm  ceases.  The  bowing  of  the  body  and  head  may  be 
repeated  as  often  as  twenty,  fifty,  or  a  hundred  times  during  the 
attack.  Facial  spasm,  blepharospasm,  strabismus,  or  a  slight 
convulsive  movement  of  one  or  other  arm,  or  of  one  of  the 
lower  extremities,  is  often  associated  with  the  spasmodic  action 
of  the  muscles  of  the  neck,  and  attacks  of  general  convulsions 
frequently  intervene,  so  that  the  case  becomes  one  of  ordinary 
epilepsy.  During  the  attack  the  child  seems  bewildered,  but 
there  is  not  complete  loss  of  consciousness,  and  as  soon  as  the 
movements  cease,  the  patient  may  be  quite  bright  and  happy. 
The  attack  may  sometimes  be  followed  by  exhaustion  and 
drowsiness. 

Diagnosis. — The  "  stiff  neck  "  produced  by  exposure  to  cold 
may  be  mistaken  for  the  tonic  form  of  torticollis.  In  the  former 
case,  any  endeavour  to  move  the  muscle  causes  great  pain,  and 
the  affection  is  usually  very  temporary  in  its  duration. 

A  tonic  spasmodic  affection  of  the  muscles  of  the  neck  may  be 
the  first  symptom  to  reveal  inflammation  of  the  cervical  vertebrae 
or  spinal  meningitis ;  in  such  cases  there  is  marked  tenderness 
on  pressure  of  the  spinous  processes,  and  some  fulness  or  hard- 
ness around  or  behind  the  vertebral  column,  and  if  the  disease 
progress,  these  symptoms  are  succeeded  by  deformity  of  the 
superior  cervical  region  of  the  vertebral  column  and  paralysis  of 
the  extremities. 

The  position  of  the  head  may  also  be  affected  by  various 
tumours  and  by  extensive  cicatrices,  but  these  cases  are  not 
likely  to  be  confounded  with  genuine  torticollis.  Torticollis  is 
sometimes  a  symptom  of  organic  diseases  of  the  brain,  accom- 
panied by  hemiplegia,  but  the  existence  of  the  paralysis  is 
sufficient  to  distinguish  such  cases  from  the  local  disease. 

Morbid  Anatomy  and  Physiology. — No  appreciable  lesion 
of  that  part  of  the  nervous  system  with  which  the  disease  is 
necessarily  associated  has  hitherto  been  detected.  According  to 
Volkmann,  irritation  of  the  spinal  accessory  nerve  in  its  passage 
through  the  foramen  lacerum  causes  contraction  of  the  sterno- 


DISEASES   OF  THE  MIXED   CRANIAL  NERVES.  561 

cleido-mastoid  and  trapezius  muscles  in  a  recently  killed  animal, 
and  Brown -Sdquard  found  that  torticollis  resulted  from  injury  to 
certain  muscles,  the  olivary  body,  or  the  auditory  nerve.  The 
disease  is  analogous  to  writers'  cramp  and  facial  spasm,  but  the 
pathology  of  all  these  spasmodic  affections  must  be  left  for  future 
investigation.  The  bilateral  clonic  variety  sometimes  results 
from  reflex  irritation,  as  that  caused  by  teething,  and  it  may 
cease  spontaneously  after  the  first  dentition.  The  tendency  of 
these  cases,  however,  is  to  pass  into  confirmed  epilepsy,  ending 
generally  in  great  impairment  of  the  intellect,  a  course  which  is 
often  followed  by  other  partial  convulsions. 

Prognosis. — When  torticollis  is  of  three  or  four  months' 
duration  it  becomes  a  most  obstinate  malady.  If  the  unilateral 
clonic  form  be  of  moderate  intensity  it  may  gradually  improve 
and  yield  to  treatment,  but  it  almost  invariably  recurs,  and  in 
the  end  resists  every  effort  made  to  remove  it.  The  general 
health  is  not  necessarily  impaired,  except  in  those  severe  cases 
in  which  the  patient  is  worn  out  by  the  constant  agitation  and 
want  of  sleep.  The  tendency  of  the  bilateral  variety  to  pass 
into  genuine  epilepsy  and  idiocy  renders  the  prognosis  much 
more  grave. 

Treatment. — For  the  tonic  variety,  myotomy  and  the  subse- 
quent application  of  a  suitable  mechanism  for  maintaining  the 
head  in  a  straight  position  are  the  proper  remedies.  In  the 
bilateral  clonic  form  all  possible  sources  of  irritation  must  be 
carefully  searched  for  and  removed,  and  if  the  convulsions  still 
continue  they  ought  to  be  treated  from  the  first  like  genuine 
epilepsy,  efficient  doses  of  the  bromide  of  potassium  being  the 
most  promising  means  at  present  known. 

The  treatment  of  the  clonic  form  has  not  hitherto  been 
attended  with  much  success.  Romberg  obtained  a  satisfactory 
result  by  progressively  increasing  doses  of  sulphate  of  zinc. 
Hammond  reports  success  with  large  doses  of  the  bromide  of 
potassium,  aod  it  is  probable  that  the  bromide  of  zinc  in 
gradually  increasing  doses  might  be  found  useful.  The  sub- 
cutaneous injection  of  morphia  and  of  atropia  have  each  been 
followed  by  great  benefit. 

Moritz  Meyer  has  been  successful  with  electricity,  but  in  the 
hands  of  others  the  use  of  this  agent  has  not  been  followed  by 
VOL.  I.  KK 


562  DISEASES  OF  THE  MIXED  CRANIAL  NERVES. 

such  brilliant  results/  although  a  certain  amount  of  benefit  has 
followed.^  The  best  method  of  employing  electricity  is  to  apply 
a  moderate  continuous  current  to  the  muscles  affected  with  spasm, 
and  a  faradic  current  to  their  antagonists.  Permanent  compression 
by  a  suitable  mechanism  over  the  points  of  arrest  has  led  to  ces- 
sation of  the  spasm,  but  in  an  apparently  successful  case  of  the 
kind  reported  by  Dr.  Heaton,^  the  spasms  recurred  after  a  time 
with  their  former  severity.^  In  the  case  of  a  policeman  kindly  sent 
to  me  by  Dr.Dacre  Fox,  and  in  whom  spasmoid  torticollis  suddenly 
developed  after  exposure  to  wet  and  cold,  a  suitable  mechanism 
was  applied  for  producing  pressure  on  the  "  point  of  arrest," 
under  Mr.  Hardie's  superintendence.  The  instrument  gave 
great  relief  to  the  patient,  but  after  treatment  for  six  months 
the  spasm  was  not  decidedly  diminished.  The  patient  then  left 
Manchester,  and  I  heard  through  Dr.  Fox  that  he  continued  to 
wear  the  instrument,  and  that  there  was  no  abatement  of  the 
spasm  until  about  six  months  afterwards,  or  twelve  from  the 
onset  of  the  disease.  About  that  time  he  went  to  bed  one  night, 
affected  as  usual,  and  woke  up  in  the  morning  finding  himself 
free  from  spasm,  and  had  no  return  of  the  symptoms  at  the  date 
of  the  report,  some  weeks  subsequently.  I  do  not  know  whether 
the  symptoms  recurred,  and  it  is  of  course  impossible  to  deter- 
mine what  share,  if  any,  the  treatment  had  in  contributing  to 
the  favourable  termination  of  the  case. 

Stretching  of  the  nerve  has  also  been  tried,  but  the  operation 
has  hitherto  only  been  attended  by  partial  success.^  A  case  is 
reported  by  Annandale,^  which  was  successfully  treated  by  division 
of  the  nerve  after  stretching  had  failed.  Division  of  the  branches 
of  the  spinal  accessory  nerve  was  attempted  by  Dr.  Bujalsky,  as 
reported  by  Stromeyer,  but  it  was  not  followed  by  any  permanent 
results.  The  operation  has,  however,  succeeded  in  the  hands  of 
De  Morgan,^  Kivington,^  and  others.     In  the  case  of  a  collier 

»  Eeynolds  (J.  E.)-    The  Lancet,  VoL  IL,  1870,  p.  532. 

'  Poore.     "Case  of  clonic  torticollis  treated  by  the  continuous  galvanic  current, 
and  the  rhythmical  exercise  of  the  affected  muscles."    Vol.  II.,  1873,  p.  520. 
^  Heaton  (J.).     British  Medical  Journal,  Vol.  I.,  1879,  p.  228. 

*  Hartridge.    The  British  Medical  Journal,  Vol.  I.,  1880,  p.  464. 

*  Southam.     The  Lancet,  Vol.  II.,  1881,  p.  369. 

'  Annandale.     The  Lancet,  Vol.  I.,  1879,  p.  555. 
'  De  Morgan.     The  Lancet,  Vol.  II. ,  1867,  p.  128. 

*  Rivington.    The  Lancet,  Vol.  I.,  1879,  p.  212. 


DISEASES   OF  THE  MIXED   CRANIAL  NERVES.  563 

receatly  under  my  own  care,  in  which  spasmodic  torticollis 
became  established  some  months  previously  after  a  severe  injury 
to  the  neck,  my  colleague,  Mr.  Heath,  divided  the  spinal  acces- 
sory nerve  on  the  side  most  affected ;  the  spasm  immediately 
ceased  and  did  not  return  when  I  saw  him  last,  three  weeks 
after  the  operation,  but  it  is  too  soon  yet  to  report  the  case  as 
one  of  permanent  cure.  Favourable  results  have  been  obtained 
by  division  of  the  affected  muscles,  an  operation  which  succeeded 
in  the  hands  of  Stromeyer,^  but  was  utterly  ineffectual  in  a  case 
where  Dieffenbach^  repeatedly  divided  the  sterno-cleido-mastoid, 
which  was  affected  by  intense  spasm.  In  a  patient  under  the 
care  of  Dr.  Ogle,*  the  sternal  attachment  of  the  sterno-cleido- 
mastoid  muscle  was  divided,  but  without  any  permanent  benefit 
to  the  patient.  The  operation  is  more  likely  to  be  successful  in 
the  tonic  than  in  the  clonic  form  of  the  disease.* 

Various  mechanical  contrivances  in  order  to  force  and  main- 
tain the  head  in  position  have  been  employed,  but,  although 
these  may  be  of  temporary  advantage,  they  cannot  be  borne 
habitually  by  patients  suffering  from  confirmed  torticollis. 

(2)  Paralysis  of  the  External  Branch  of  the  Spinal  Accessory 

Nerve. 

§  281.  Etiology. — Paralysis  in  the  region  of  distribution  of  the 
spinal  accessory  is  generally  of  peripheral  origin,  and  results  from 
compression  of  the  nerve  by  tumours,  enlarged  lymphatic  glands, 
abscesses,  disease  of  the  bones  of  the  skull,  or  from  traumatic 
injuries  to  the  nerve.  Paralysis  may  also  result  from  exposure 
to  cold,  or  from  neuritis  in  whatever  way  it  may  be  produced. 
The  muscles  supplied  by  the  spinal  accessory  nerve  may  also  be 
paralysed  and  atrophied  in  progressive  muscular  atrophy. 

Symptoms. — Paralysis  of  the  sterno-cleido-mastoid  and  tra- 
pezius muscles  may  be  unilateral  or  bilateral ;  and  the  muscles 
may  be  separately  or  simultaneously  affected. 

'  Stromeyer,     Beitrage  zur  operativen  Orthopsedik,  1838,  p.  128  et  seq. 

'^  Diefifenbach.  Ueber  den  Durchschneidung  der  Sehnen  und  Muskelm,  BerL, 
1841.     p.  24. 

^  Ogle  (J.  W.).  '"Clonic  spasmodic  contraction  of  the  muscles  of  the  neck 
possibly  having  its  origin  in  some  aflfection  of  the  contents  of  the  spinal  canal." 
Clinical  Society  Transactions,  VoL  VI.,  1873,  p.  114. 

*  See  Fischer.     The  Lancet,  Vol.  II.,  1877,  p.  609. 


5Q4:  DISEASES   OF  THE  MIXED   CRANIAL  NERVES. 

In  unilateral  paralysis  of  the  sterno-cleido-mastoid  the  head 
is  held  in  an  oblique  position,  the  chin  is  elevated  and  turned 
towards  the  affected  side,  the  prominence  of  the  healthy  muscle 
on  its  movements  being  resisted  is  absent,  and  the  head  can 
only  be  moved  in  the  opposite  direction  with  difficulty  and  by 
the  aid  of  other  muscles,  but  passive  movements  can  be  readily 
performed.  In  chronic  cases  contraction  of  the  healthy  muscle 
occurs,  and  causes  the  head  to  assume  a  persistent  oblique 
position. 

With  bilateral  paralysis  of  the  sterno-cleido-mastoid  muscles 
the  head  is  held  straight,  but  rotation  of  it  can  only  be  per- 
formed with  difficulty,  especially  when  the  chin  is  elevated.  The 
prominence  of  the  muscles  is  absent,  the  neck  looks  wasted,  and, 
if  atrophy  be  present,  a  slight  depression  is  produced  between 
the  mastoid  process  and  the  sternum. 

In  paralysis  of  the  trapezius  the  scapula  of  the  affected  side 
is  drawn  somewhat  downwards  and  forwards  ;  its  inner  border  is 
separated  from  the  vertebral  column  and  assumes  an  oblique 
position,  the  inferior  angle  being  nearer  than  the  superior  to  the 
vertebral  column.  The  acromion  process  falls  downwards  and 
forwards,  partly  from  the  weight  of  the  arms  and  partly  from 
the  antagonistic  action  of  the  rhomboid  muscles  and  the  levator 
anguli  scapulae,  and  consequently  the  clavicle  projects  and  thus 
makes  the  supra-clavicular  fossa  deeper  than  natural,  and  the 
posterior  and  superior  angle  of  the  scapula  can  be  felt  with 
unusual  distinctness.  The  trapezius  derives  its  nervous  supply 
from  various  sources,  hence  partial  paralysis  of  the  muscle  is  not 
uncommon,  and  in  such  cases  the  position  of  the  scapula  differs 
to  some  extent  according  as  the  upper,  middle,  or  lower  third 
of  the  muscle  is  paralysed.  The  upper  third  of  the  trapezius 
draws  the  acromion  upwards  and  backwards,  and  paralysis  of 
this  portion  of  the  muscle  renders  elevation  of  the  arm  above 
the  horizontal  line  difficult. 

If  the  paralysis  be  bilateral,  the  symptoms  are  present  on 
both  sides,  both  shoulder  blades  fall  outwards  and  forwards,  the 
head  readily  sinks  on  the  chest,  and  some  difficulty  is  expe- 
rienced in  maintaining  it  in  an  upright  and  straight  position. 

If  both  the  sterno-cleido-mastoid  and  trapezius  muscles  be 
simultaneously  affected,  the  symptoms  of  the  separate  paralyses 


DISEASES  OF  THE  MIXED  CRANIAL  NERVES.  565 

are  combined,  and  then  the  internal  branch  of  the  spinal  acces- 
sory is  not  unfrequently  implicated. 

Treatment. — An  endeavour  must  be  made  to  remove  the 
cause,  and  subsequent  electrical  treatment  is  of  the  greatest 
importance.  Deformities  produced  by  secondary  contractions 
must  be  removed  by  the  aid  of  active  and  passive  gymnastics, 
tenotomy,  and  va,rious  mechanical  appliances. 


566 


CHAPTEE   VI. 


DISEASES    OF    THE   CERVICAL   AXD    BRACHIAL    PLEXUSES. 

(I.)-DISEA&ES    OF   THE   CERVICAL    PLEXUS. 

The  diseases  of  the  cervical  plexus  may  be  divided  into  (A) 
sensory,  and  (B)  motor  disorders, 

(A)  Sensory  Disorders  of  the  Cervical  Plexus. 

The  sensory  disorders  of  the  cervical  plexus  may  be  sub- 
divided into  (1)  cervico-occipital,  and  (2)  phrenic  neuralgia. 

(1)  Cervico-Occipital  Neuralgia. 

§  282.  Cervico-occipital  neuralgia  has  its  seat  in  the  region  to 
which  the  sensory  fibres  of  the  four  upper  cervical  nerves  are 
distributed.     The  cutaneous  nerves  of  the  cervical  plexus  are: — 

(1)  The  great  occipital  nerve,  distributed  to  the  whole  of  the 
occipital  and  posterior  parietal  regions  as  far  as  the  vertex  ; 

(2)  the  small  occipital  nerve,  which  is  distributed  over  the  side 
of  the  back  part  of  the  head  as  far  forwards  as  the  ear ;  (3)  the 
great  auricular  nerve,  which  supplies  the  face,  the  parotid  region, 
and  the  back  of  the  external  ear  ;  (4)  the  inferior  subcutaneous 
nerve  of  the  neck,  which  is  distributed  over  the  anterior  region 
of  the  neck,  the  chin,  and  the  side  of  the  cheek ;  and  (5)  the 
supra-clavicular  nerves,  which  ramify  throughout  the  clavicular 
and  upper  thoracic  regions  and  the  lower  part  of  the  neck, 

Cervico-occipital  neuralgia  may  therefore  be  widely  spread, 
but  the  area  of  distribution  of  the  great  occipital  nerve  is  the 
reo-ion  usually  affected.  This  form  of  neuralgia  has  a  tendency 
to  spread  to  the  lower  part  of  the  face,  and  then  it  becomes 


DISEASES  OF  CERVICAL  AND  BRACHIAL  PLEXUSES.         567 

almost  indistinguishable  from  neuralgia  of  the  third  division  of 
the  trigeminus.  It  is  sometimes  accompanied  by  great  irritation 
and  swelling  of  the  submaxillary  and  cervical  glands, 

Cervico-occipital  neuralgia  is  usually  excited  by  exposure  to 
draughts  of  cold  air,  and  it  may  occasionally  be  the  result  of 
injury  or  disease  of  the  upper  cervical  vertebrae; 

PaAnful  points  are  usually  met  with  in  this  form  of  neural^a ;  most 
frequently  at  the  point  of  emergence  of  the  great  occipital  nerve,  about 
midway  between  the  mastoid  process  and  the  spinous  processes  of  the- 
ujDper  cervical  vertebrse  (occipital  point).  The  track  of  the  nerve  over  the 
occiput  is  often  painful.  A  point  over  the  parietal  eminence  (the  parietal 
point),  and  the  spinous  processes  of  the-  upj)er  cervical  vertebrse,  are 
generally  tender  to  the  touch. 

The  pain  in  this  form  of  neuralgia  usually  radiates  widely, 
affecting  most  frequently  the  brows,  temples,  and  cheeks;  this 
leads  to  its  being  sometimes  mistaken  for  trigeminal  neuralgia. 
The  ordinary  accompaniments  of  neuralgia  may  be  observed,  as 
hypersesthesia  or  anaesthesia  of  the  skin  of  the  occipital  region,, 
and  spasm  or  tonic  contractions  of  the  cervical  muscles. 

The  treatment  of  cervico-occipital  neuralgia  does  not  require 
any  special  mention,  inasmuch  as  it  should,  be  conducted  on  the 
general  principles  already  detailed. 

(2)  Phrenic  Neuralgia. 

§  283.  A  form  of  neuralgia  has  been  described  by  Peter,^- 
which  he  believes  to  have  its  seat  in  the  phrenic  nerve.  The 
author  thinks  that  the  phrenic  is  a  mixed,  instead  of  being,  as  is- 
generally  supposed,  a  purely  motor  nerve ;  but  the  observations 
of  Ziemssen^  upon  a  case,  in  which  a  large  portion  of  the  anterior 
wall  of  the  left  half  of  the  thorax  had  been  excised  for  the 
removal  of  an  enchondroma,  and  the  heart  consequently  laid 
bare,  shows  conclusively  that  the  latter  or  generally  accepted 
view  must  still  be  maintained.  The  symptoms  of  this  affection, 
as  described  by  Peter,  are  severe  pain  at  the  point  where  the 

'Peter  (M.).  "  Nevralgie  diaphragmatique  et  faits  morbides  connexes." 
Archives  Ge'ne'ral  de  M^decine,  VI«  Serie,  Tome  XVII.,  1871,  p.  303. 

^  Ziemssen.  ' '  Studien  iiber  die  Bewegungs-vorgange  am  menschlichen  Herzen 
sowie  iiber  die  mechanische  und  elektrische  Erregbarkeit  des  Herzena  und  des 
Nervus  phrenicus,  angestellt  an  dem  freiliegenden  Herzen  der  Catharina  Serafin." 
Deutsches  Arch.  f.  klin.  Med.,  Bd,  XXX.,  1882,  p.. 286. 


568 


DISEASES   OF  THE  CEEVICAL 

Fig.  71. 


Fig.  71.  Na-ves  of  the  Cervical  Plexus. 

IC,  lie,  IIIC,  IVC,  First,  second,  third,  and  fourth  cervical  nerves. 

1,  Muscular  branch  to  rectus  capitis  posticus  major  and  minor. 
1',  „  ,,  obliquus  superior. 

1",  ,,  ,,  complexus. 

2,  ,,  „  obliquus  inferior. 

2f,  „  ,,  complexus  and  trachelo-mastoid. 

2",  ,,  ,,  splenius. 

3,  „  „  muscles  of  the  neck. 

4,  ,,  ,,  muscles  of  the  neck. 

G  0,  Great  occipital  nerve,  cutaneous  to  posterior  part  of  scalp. 
CO,  Cutaneous  branch  to  posterior  part  of  scalp  and  back  of  neck. 

5,  Muscular  branches  to  rectiis  capitis  lateralis. 

5',  ,,  ,,  rectus  capitis  anticus  major  and  minor. _ 

5",  Communicating  branches  with  hypoglossal  and  pneumogastric  nerves. 
SO,  Small  occipital  nerve. 

6,  Muscular  branch  to  occipito  frontalis  muscle. 


AND  BRACHIAL  PLEXUSES.  569 

nerve  takes  its  origin  from  the  cervical  plexus  and  descends 
over  the  scalenus  anticus,  in  the  course  of  the  nerve  through  the 
chest,  at  the  lower  and  anterior  part  of  the  thorax,  and  along 
the  line  of  attachment  of  the  diaphragm.  Pain  in  the  shoulder 
is  also  almost  a  constant  and  characteristic  symptom  of  the 
affection.  This  form  of  neuralgia  is  sometimes  met  with  as  a 
separate  affection,  but  it  is  usually  complicated  by  hysteria  or 
epilepsy,  and  above  all  by  angina  pectoris. 

The.  painful  points  are  (1)  the  spinous  processes  of  the  upper  cervical 
vertebras,  especially  from  the  second  to  the  fifth  ;  (2)  the  phrenic  nerve 
itself  in  its  course  along  the  supra-clavicular  fossa  ;  (3)  the  Hne  of  attach- 
ment of  the  diaphragm,  especially  anteriorly  between  the  seventh  and 
tenth  ribs,  and  more  rarely  posteriorly  ;  (4)  a  point  over  the  cartilage  of 
the  third  rib. 

(B)  Motor  Disorders  of  the  Cervical  Plexus. 

The  motor  disorders  of  the  cervical  plexus  may  be  divided 
into  (1)  spasm,  and  (2)  paralysis,  of  the  muscles  supplied  by  it. 
But  inasmuch  as  the  nervous  affections  of  the  diaphragm  cannot 
be  separated  without  violence  from  the  motor  affections  of  the 
remaining  respiratory  muscles,  we  shall  include  in  these  sub- 
divisions the  spasmodic  and  paralytic  diseases  of  the  muscles 
supplied  by  the  dorsal  nerves. 

(1)  Spasm  op  the  Muscles  supplied  by  the  Cervical  and  Dorsal 

Nerves. 

§  284.  The  following  groups  of  muscular  spasms  may  be 
distinguished  in  the  region  of  distribution  of  the  cervical  and 
dorsal  nerves. 


6',  Auricular  branch  to  attollens  aurem. 

7,  Muscular  branch  to  sterno-cleido-mastoideus,  communicating  with  spinal 

accessory  nerve. 
GA,  Great  auricular  nerve. 

m,  Mastoid  branch  to  integument  behind  ear. 
a,  Auricular  branch  to  external  ear. 

/,  racial  branch  to  integument  of  face  over  parotid  gland. 
SC,  Superficial  cervical  nerve  to  anterior  and  lateral  parts  of  neck  and  muscular  to 

platysma. 
CN,  Communieans  noni  joining  descending  branch  of  hypoglossal  nerve. 

8,  Muscular  branch  to  levator  anguli  scapulae. 

9,  ,,    _        ,,  trapezius  communicating  with  spinal  accessory  nerve. 
S  c,  Supra-clavicular  nerves,  or  descending  branches. 

C,  Commuuicating  branch  to  brachial  plexus. 
P,  Phrenic  nerve. 


570 


DISEASES   OF   THE   CERVICAL 


{a)  Spasm  of  Individual  Muscles  and  Groups  of  Muscles  in 

the  Neck. 

(i.)  Spasm  of  the  Splenius  Capitis. — Id  spasm  of  this  muscle 
the  head  is  drawn  backwards  and  towards  the  affected  side ;  the 
chin  is  somewhat  depressed  and  directed  towards  the  side  of  the 
spasm,  and  not  to  the  opposite  side,  as  in  spasm  of  the  trapezius, 
and  a  hard  ridge  can  be  felt  at  the  point  where  the  splenius 
appears  beneath  the  anterior  border  of  the  trapezius.  The 
spasm  is  generally  tonic,  with  remissions  and  occasional  more 
energetic  contractions. 

(ii.)  Spasm,  of  the  Obliquus  Capitis  Inferior. — Spasm  of  this 
muscle  causes  either  intermittent  or  persistent  rotation  of  the 
head  around  its  vertical  axis,  without  any  elevation  of  the  chin 
or  depression  of  the  mastoid  process.  In  clonic  spasm  the 
patient  may  often  be  observed  to  correct  the  oblique  position  of 
the  head  with  the  hand  when  walking,  or  when  he  wishes  to 
speak,  or  to  look  at  a  fixed  object. 

(iii.)  Spasm  of  the  deep  muscles  of  the  nech  is  characterised  by 
strong  backward  retraction  of  the  head  when  the  affection  is 

Fig.  72. 


Fig,  72.  Spasm  oj  Splenius. 


AND  BKACHIAL   PLEXUSES.  571 

bilateral,  or  towards  the  affected  side  when  it  is  unilateral.  A 
large  proportion  of  all  the  cases  of  spasms  in  the  neck  are  due  to 
implication  of  the  muscles  at  the  back  of  the  neck. 

The  treatment  is  the  same  in  principle  as  that  for  spasm  of 
the  sterno-mastoid. 

(6)  Spasms  of  the  Respiratory  Muscles. 

(i.)  Tonic  Spasm  of  the  Diaphragm. — This  affection  is  for- 
tunately rare.  It  induces  great  dyspnoea,  the  patients  being 
threatened  with  asphyxia.  The  lower  half  of  the  chest  is  ex- 
panded and  immovable,  and  the  epigastrium  strongly  projects, 
whilst  rapid  and  superficial  respirations  are  performed  with  the 
upper  part  of  the  chest.  There  is  severe  pain  in  the  epigastrium 
and  along  the  attachments  of  the  diaphragm,  the  patient  is 
compelled  to  sit  up  in  bed,  the  voice  becomes  feeble  and  muffled, 
and  there  is  well-marked  cyanosis ;  if  the  attack  last  beyond  a 
short  time,  death  ensues.  This  kind  of  spasm  of  the  diaphragm 
is  often  the  immediate  cause  of  death  in  tetanus.  It  is  occa- 
sionally a  complication  in  tetany ;  when  it  occurs  as  an  unmixed 
affection,  it  is  generally  caused  by  exposure  to  cold,  and  on  this 
account  is  usually  regarded  as  a  rheumatic  affection  of  the 
diaphragm  itself. 

Treatment. — The  treatment  must  be  very  energetic,  as  death 
may  supervene  in  a  few  minutes  unless  relief  is  obtained.  In- 
halation of  chloroform,  subcutaneous  injection  of  morphia,  hot 
fomentations,  faradisation  with  the  brush  and  a  strong  current 
applied  in  the  neighbourhood  of  the  diaphragm,  and  the  appli- 
cation of  galvanic  and  faradic  electricity  in  the  course  of  the 
phrenic  nerves,  are  the  remedies  to  be  mainly  relied  upon. 

(ii.)  Clonic  Spasm,  of  the  Diaphragm,  Singultus,  Hiccough. — 
Everyone  is  familiar  with  hiccough.  It  consists  of  short,  ener- 
getic, spasmodic  contractions  of  the  diaphragm  accompanied  by 
an  inspiratory  sound,  which  is  usually  suddenly  arrested  by  the 
closure  of  the  glottis.  The  contractions  may  succeed  each  other 
rapidly;  often,  indeed,  so  rapidly  that  a  hundred  contractions 
occur  in  a  minute.  The  attack  may,  on  the  one  hand,  last  only 
a  few  minutes ;  and  on  the  other,  for  hours,  days,  or  weeks,  and 
may  recur  more  or  less  frequently  for  years. 


572  DISEASES   OF   THE   CERVICAL 

When  the  spasms  are  violent  severe  pain  is  experienced  in  the 
epigastrium  and  along  the  attachments  of  the  diaphragm.  If 
the  hiccough  is  frequent,  dyspnoea  occurs,  and  the  rhythm  of 
respiration  and  articulation  is  considerably  disturbed.  The  in- 
gestion of  food  is  interfered  with,  digestion  is  imperfect,  rest 
is  disturbed,  and  the  spasm  is  not  always  arrested  during  sleep. 
Hiccough  has  been  observed  in  diseases  of  the  central  nervous 
system  and  in  injuries  of  the  skull  and  cervical  portion  of  the 
spinal  column.  Amongst  other  causes  of  hiccough  may  be 
mentioned  emotional  disturbances,  hysteria,  malarial  poison, 
chlorosis,  and  cachexia.  Hiccough  is,  however,  more  frequently 
caused  by  reflex  irritation,  proceeding  from  the  subjacent  viscera. 
Simple  repletion  or  pressure  on  the  stomach  may  cause  it,  and  it 
is  frequently  observed  in  gastric  and  intestinal  diseases  of  all 
kinds,  in  peritonitis,  in  hepatic  and  uterine  affections,  in  disturb- 
ances of  menstruation,  and  in  affections  of  the  prostate  gland. 
It  may  sometimes  follow  a  prolonged  fit  of  coughing,  and  has 
been  observed  associated  with  pericarditis.  It  is  generally  an 
ominous  sign  in  cancer  of  the  abdominal  viscera  and  in  other 
cachectic  conditions. 

The  prognosis  is  in  most  cases  favourable,  although  in 
hysterical  and  other  nervous  affections  it  often  resists  treat- 
ment in  the  most  obstinate  manner.  The  final  hiccough  in 
cachectic  conditions  naturally  carries  with  it  a  bad  prognosis. 

Treatment — The  first  object  of  treatment  is  to  remove  the 
cause.  In  slight  cases  mental  impressions,  such  as  fright  and 
strong  diversion  of  the  attention  in  another  direction,  are  often 
successful  in  removing  the  disease.  A  powerful  expiratory  effort 
sometimes  removes  the  spasm ;  Cruveilhier  suggested  a  plan 
which  he  found  successful,  namely  to  pour  water  into  the  mouth 
until  the  patient  fears  that  he  is  about  to  be  suffocated.  These 
methods  probably  act  in  a  reflex  manner. 

In  order  to  induce  the  necessary  expiratory  effort  the  patient 
may  be  directed  to  hold  his  breath  as  long  as  possible,  to  strain 
with  closed  glottis,  or  to  inhale  a  strong  odour  or  pungent  smell 
so  as  to  induce  sneezing.  When  the  spasm  does  not  give  way 
with  these  simple  methods,  hot  fomentations  or  a  blister  may  be 
applied  over  the  diaphragmatic  region.  The  faradic  brush  applied 
in  full  strength  over  the  epigastrium  and  hypochondria  is  very 


AND  BRACHIAL  PLEXUSES.  573 

effective.     Galvanisation  or  faradisation  along  the  course  of  the 
phrenic  nerves  is  very  useful. 

Narcotics  are  also  useful,  the  best  being  subcutaneous  injec- 
tion of  morphia ;  opium  in  other  forms,  cannabis  indica,  and 
atropine  have  also  been  successfully  tried.  The  inhalation  of 
ether  or  chloroform  may  be  necessary  in  obstinate  cases. 

The  nervine  tonics,  such  as  zinc,  valerian,  assafsetida,  arsenic, 
strychnine,  and  nitrate  of  silver,  may  be  tried  in  severe  cases. 

(iii.)  Inspiratory  Spasm  (Spasmus  Inspiratorius). — In  inspi- 
ratory spasm  there  is  a  spasmodic  rhythmic  contraction  of  all,  or 
almost  all,  the  inspiratory  muscles.  True  inspiratory  spasm 
differs  considerably  from  hiccough,  although  the  latter  frequently 
complicates  the  former.  The  essential  feature  of  the  affection  is 
that  either  many  or  all  of  the  muscles  of  inspiration  participate 
in  the  spasm,  and  that  a  true  inspiration,  unbroken  by  sudden 
closure  of  the  glottis,  takes  place.  The  spasm  consists  in  a  more 
or  less  rapid  succession  of  deep  inspirations,  whilst  the  intervening 
expirations  are  performed  in  the  usual  noiseless  way.  The  chest 
is  powerfully  expanded,  the  epigastrium  is  protruded,  the  auxiliary 
muscles  of  respiration  are  excited  to  action,  the  pectoral  and 
stern o-cleido-mastoid  muscles  are  brought  into  strong  relief,  the 
shoulders  are  raised,  the  head  is  drawn  backwards,  and  the 
respiratory  muscles  of  the  face,  alae  nasi,  and  eyelids  contract. 
Inspiration  is  noisy,  and  it  is  often  accompanied  by  eructation  of 
gas  from  compression  of  the  stomach.  The  spasm  usually  occurs 
in  paroxysms  of  variable  duration,  the  abdomen  is  generally 
tympanitic,  and  there  are,  as  a  rule,  other  symptoms  of  nervous 
derangement,  especially  those  characteristic  of  hysteria. 

(iv.)  AttacJcs  of  Sneezing  (Sternutatio  Convulsiva). — Attacks 
of  sneezing  occur  in  a  paroxysmal  and  spasmodic  form,  so  that 
the  patient  will  sometimes  sneeze  several  hundred  times  in  suc- 
cession. Ordinary  sneezing  is  a  reflex  act  excited  by  irritation  of 
the  nasal  filaments  of  the  fifth  pair.  Attacks  of  sneezing  are 
generally  accompanied  by  a  profuse  watery  secretion  from  the 
nasal  cavities ;  and,  when  of  long  duration,  they  cause  great 
misery  to  the  patient. 

(v.)  Attacks  of  Yawning  (Oscedo,  Chasma). — Chasma  con- 
sists of  a  succession  of  yawns  following  each  other  with  greater 
or  less  rapidity,  and  accompanied  by  the  well-known  phenomena 


574  DISEASES   OF  THE   CERVICAL 

of  gaping,  flow  of  saliva,  secretion  of  tears,  and  diminution  in 
the  acuteness  of  hearing  with  dull  tinnitus  aurium. 

(vi.)  Spasmodic  cough  comprises  all  those  paroxysmal  attacks 
of  coughing  which  are  accompanied  by  a  loud,  ringing  sound. 
Such  attacks  of  coughing  may  last  for  a  variable  period,  and 
may  also  recur  frequently  for  months  or  years. 

(vii.)  Fits  of  laughing  or  crying  are  forms  of  expiratory 
spasm.  The  former  consists  of  a  succession  of  loud  expirations 
accompanied  by  vocal  tones ;  the  latter  consists  of  long-drawn 
expirations,  often  interrupted  by  sobs,  accompanied  by  wailing 
or  moaning  sounds,  and  generally  by  a  profuse  secretion  of  tears. 
These  actions  are  usually  associated  with  well-known  mental 
states,  and  accompanied  by  characteristic  facial  expressions;  they 
may  be  quite  independent  of  emotional  disturbances  in  patho- 
logical conditions,  and  then  constitute  subordinate  symptoms  of 
severe  general  neuroses,  such  as  hysteria,  or  are  produced  by 
disease  of  the  central  nervous  system. 

Treatment — The  first  object  of  treatment  is  to  remove  the 
cause,  such -as  any  source  of  reflex  irritation  or  hysteria.  The 
direct  treatment  of  these  forms  of  spasm  must  be  conducted 
by  cutaneous  irritants,  electro- therapeutics,  narcotics,  and  anti- 
spasmodics. For  the  cure  of  sneezing,  compression  of  the  nose, 
plunging  the  head  into  cold  water,  sponging  the  face  and  nose 
in  hot  water,  counter-irritation  of  the  skin,  emetics,  inhalation 
of  chloroform,  or  of  the  vapour  of  iodine,  may  be  successively 
tried.  Helmholtz  has  recommended  the  local  application  of 
solution  of  quinine  to  the  nasal  mucous  membrane  in  cases  of 
hay  asthma,  and  in  ordinary  cases  of  nasal  catarrh  I  have  found 
the  most  distressing  symptoms  to  be  much  relieved  by  lubri- 
cating the  mucous  membrane  with  vaseline. 

(2)  Paralysis  of  the  Eespiratory  Muscles. 

§  285.  The  muscles  of  inspiration  are  widely  separated  from  one 
another  in  position,  and  are  innervated  by  various  nerves. 

(a)  Complete  paralysis  occurs  when  the  respiratory  centres 
in  the  medulla  oblongata  are  affected.  The  medulla  may  be 
affected  by  various  degenerative  processes  which  implicate  the 
respiratory  centres,  and  the  action  of  various  poisons  arrests 
their  functional  activity.     Paralysis  of  the  muscles  of  respiration 


AND  BRACHIAL   PLEXUSES.  575 

may  also  occur  when  the  motor  tracts  proceeding  from  these 
centres,  which  run  in  the  lateral  columns  of  the  cord,  are 
destroyed,  as  occurs  in  compression  of  the  cord  from  fracture  of 
the  upper  cervical  vertebrae,  and  in  these  cases  rapid  death  is 
inevitable. 

(b)  Unilateral  jparalysis  of  the  fibres  in  their  course  through 
the  spinal  cord,  which  is  sometimes  observed,  does  not  imme- 
diately endanger  life.  The  respiratory  processes  are  not  much 
interfered  with  in  cerebral  paralysis. 

(c)  Peripheral  imralyses  of  the  respiratory  muscles  usually 
affect  only  individual  muscles  or  a  group  of  muscles.  The  inter- 
costals,  the  scaleni,  and  other  auxiliary  inspiratory  muscles  may 
be  affected ;  but  by  far  the  most  important  muscle  of  inspiration 
is  the  diaphragm,  and  when  it  is  paralysed  serious  interference 
with  the  respiratory  process  is  occasioned. 

{d)  Diaphragmatic  paralysis  is  on  the  whole  rare ;  when  it 
occurs  it  is  usually  bilateral,  but  occasionally  it  may  be  partial 
or  unilateral.  It  may  result  from  pleurisy  or  peritonitis  when 
the  portions  of  these  serous  membranes  which  cover  the  dia- 
phragm are  inflamed,  but  in  these  cases  the  muscle  is  directly 
affected.  It  may  also  occur  as  a  late  symptom  of  progressive 
muscular  atrophy,  it  is  occasionally  observed  in  hysterical 
patients,  and  Duchenne  has  observed  it  as  a  consequence  of 
lead  poisoning.  Exposure  to  a  chill  may  cause  the  disease, 
especially  in  young  people,  either  by  producing  rheumatic 
paralysis  of  the  phrenic  nerve  or  by  causing  muscular  rheu- 
matism of  the  diaphragm.  Paralysis  of  the  phrenic  nerve  may 
also  be  caused  by  wounds  or  the  presence  of  tumours  in  the 
neck,  and  under  these  circumstances  the  paralysis  is  apt  to  be 
unilateral. 

The  symptoms  of  diaphragmatic  paralysis  are  highly  charac- 
teristic. During  inspiration  the  epigastrium  and  hypochondria 
are  drawn  inwards  instead  of  being  curved  outwards,  and  if  the 
hand  be  placed  on  the  epigastrium,  the  protrusion  caused  in 
health  by  the  descending  diaphragm  cannot  be  perceived  during 
inspiration,  while  it  may  be  felt  to  project  slightly  during 
expiration.  When  the  paralysis  is  unilateral,  these  symptoms 
occur  only  on  one  side,  but  they  may  be  distinctly  detected  by 
palpation. 


576  DISEASES   OF  THE  CERVICAL 

During  rest  the  frequency  of  inspiration  is  not  much  in- 
creased, but  if  the  slightest  exertion  is  made  dyspnoea  is  at  once 
experienced,  and  the  frequency  of  respiration  rises  to  forty  or 
fifty  in  a  minute.  Paralysis  of  the  diaphragm  is  always  a  serious 
affection,  and  the  danger  is  much  increased  by  intercurrent 
attacks  of  bronchitis  or  pneumonia.  The  contents  of  the  bladder 
and  rectum  are  expelled  with  difficulty,  because  the  action  of 
the  abdominal  muscles  is  rendered  ineffective  owing  to  the 
absence  of  the  counter  pressure  afforded  by  the  contracted 
diaphragm. 

The  diagnosis  of  diaphragmatic  paralysis  presents  no  special 
difficulty.  The  prognosis  depends  upon  the  cause.  It  is  favour- 
able in  rheumatic  and  hysterical  paralysis ;  it  is  doubtful  in  lead 
paralysis,  and  very  unfavourable  in  progressive  muscular  atrophy, 
although  even  in  the  latter  case  considerable  improvement  may 
be  produced  by  appropriate  treatment. 

Treatment. — The  treatment  must  first  be  directed  to  remove 
the  cause.  Recourse  should  be  had  at  an  early  period  to  fara- 
disation or  galvanisation  of  the  phrenics,  which  can  be  easily 
applied  in  the  neck  over  the  scaleni,  the  other  pole  being  placed 
upon  the  back  of  the  neck,  or  over  the  attachments  of  the 
diaphragm  to  the  ribs. 

(II.)- DISEASES  OE  THE  BEACHIAL  PLEXUS. 

The  brachial  plexus  is  formed  by  the  union  of  the  anterior 
trunks  of  the  four  lower  cervical  and  first  dorsal  nerves,  along 
with  a  fasciculus  from  the  fourth  cervical  nerve.  The  mode  of 
formation  of  the  plexus  and  its  branches  of  distribution  are 
shown  in  the  annexed  diagram  {Fig.  73);  the  distribution  of  the 
sensory  branches  of  the  plexus  are  shown  in  Figs.  74  and  75 ; 
and  that  of  the  sensory  nerves  to  the  back  of  the  hand  in 
Fig.  76. 

§  286.  Functions  of  the  Brachial  PZescws.— Several  endeavours  have  been 
made  both  by  anatomists  and  physiologists,  as  well  as  by  physicians,  to 
determine  the  functions  of  the  respective  nerves  which  enter  into  the 
formation  of  the  brachial  plexus.  The  purely  anatomical  method  consists, 
of  course,  of  dissection  of  the  plexus.  After  maceration  of  the  plexus  in 
dissociating  fluid,  W.  Krause  was  enabled  to  trace  back  the  various  fibres  of 
each  nerve  to  the  roots  from  which  they  were  derived.     His  general  con- 


AND   BRACHIAL   PLEXUSES.  577 

elusions  with  regard  to  the  origin  of  the  nerves  of  the  upper  extremity 
from  the  roots  of  the  plexus  are  given  in  the  following  table  from  Quain's 
"  Anatomy  "  : — 


Subscapular       ...      -s 

Circumflex >  3,  6,  7,  8. 

Musculo-spiral  ...      ) 
External  cutaneous      5,  6,  7. 
Median       ...        5,  6,  7,  8,  1. 


Ulnar     8,  1,  or  7,  8,  1. 

Internal  cutaneous      •••  /  n 

Small  internal  cutaneous  )    ' 

.    .     .     . ,         .    {  outer  5,  6,  7. 
Anterior  thoracic  <  .         „     ' 
( inner  8,  1. 


The  physiological  method  consists  in  observing  the  results  of  destruc- 
tion or  of  excitation  of  the  various  roots  of  the  plexus.  Experiments  of 
this  kind  have  been  performed  on  various  animals  by  Miiller^  and  van 
Deen,  Kronenberg,^  Panizza,^  Peyer,*  Krause,^  and  more  recently  by  Pro- 
fessors Ferrier  and  Yeo.^  The  results  obtained  from  electrical  excitation 
of  the  different  roots  of  the  brachial  plexus  in  the  monkeys  by  the  last- 
named  authors  are  the  following : — 

"First  Dorsal. — Action  of  the  intrinsic  muscles  of  the  hand,  muscles  of 
ball  of  thumb,  interossei,  &c. 

"Eighth  Cervical. — Closure  of  the  fist  with  pronation  and  ulnar  flexion 
of  wrist,  retraction  of  arm  with  extension  of  the  forearm.  (Long  flexors, 
ulnar  flexors  of  wrist,  intrinsic  muscles  of  hand,  extensors  of  wrist  and 
phalanges,  long  head  of  tricexas,  (pectoralis  major  ?).) 

"  Seventh  Cervical. — The  scalptor  ani  action,  viz.,  adduction  with  rotation 
inwards  and  retraction  of  upper  arm,  extension  of  forearm  and  flexion  of 
wrists  and  fingers  so  as  to  bring  the  tips  against  the  flanks  (teres  major, 
latissimus  dorsi,  subscapularis,  pectoralis  major,  flexors  of  wrist  and  fingers 
(median),  triceps). 

"/Sixth  Cervical. — The  movement  of  'attention,'  viz.,  adduction  and 
retraction  of  upper  arm,  extension  of  forearm,  pronation  and  flexion  of 
wrist,  the  palm  of  the  hand  being  brought  towards  pubes  (latissimus  dorsi, 
pectoralis  major,  serratus  magnus,  pronators,  (flexors  of  wrist?)  triceps). 

"Fifth  Cervical. — Movement  of  the  hand  towards  the  mouth,  viz., 
raising  the  upper  arm  inwards,  flexion  of  the  forearm  with  supination, 
and  extension  of  the  wrist  and  fingers  (deltoid  (clavicular  portion),  biceps, 
brachiaUs  anticus,  serratus  magnus,  supinator  longus,  extensors  of  wrist 
and  fingers). 

1  Miiller's  Physiology,  translated  by  Balz.     Vol.  I.,  1838,  p.  682. 
^  Kronenberg.     Plexuum  nervorum  structura  et  virtutes.     Berol.,  1836. 
^  Panizza.      See   Froriep's   Notizen,    "  Experimental-untersuchungen  iiber  die 
Nerven."    No.  945,  March,  1835,  p.  321, 

*  Peyer._  "  Ueber  die  peripherischen  endigungen  der  motorischen  und  sensiblen 
Fasern  der  in  den  Plexus  brachialis  Kaninchens  eintretenden  Nerven wurzeln."  Zeit- 
schrift  fur  rat.  Med.     N.F.,  Bd.  IV.,  1854,  p.  52. 

*  Krause  (W.).  Beitrage  zur  Neurologie  der  oberen  Extremitat,  1865;  und 
Anatomie  des  Kaninchens,  1868,  p.  247. 

^  See  Ferrier  (D.)  and  Yeo  (G.).  "  On  the  Functional  Relations  of  the  Motor 
Roots  of  the  Brachial  and  Lumbo-sacral  Plexuses."  Proceedings  of  the  Royal 
Society,  Vol.  XXXII.,  March  24  to  June  16,  1881,  p.  12. 

VOL.  L  LL 


578 


DISEASES   OF   THE   CERVICAL 
Fig.  73. 


Fig.  73  (after  Flower).    Nerves  of  the  Brachial  Plexus. 

VC,  VIC,  VIIC,  VIIIO,  ID,  IID,  HID,  Fifth,  sixth,  seventh,  and  eighth  cervical, 

and  first,  second,  and  third  dorsal  nerves. 
CB,  Communicating  branch  from  the  fourth  cervical  nerve. 


AND  BRACHIAL  PLEXUSES.  579 

P,  Phrenic  nerve. 

c,  c,  Dorsal  cutaneous  branches  from  the  fifth  cervical  to  the  third  dorsal  nerve. 

M,  M,  Branches  to  the  muscles  of  the  neck  and  back. 

B,  Branch  to  the  scalenus  medius. 

S',  Branch  to  the  subclavius  muscle. 

I,  I',  Branches  to  rhomboideus  major  and  rhomboideus  minor. 
SS,  Supra  scapular  nerves  : — 

2,  Branch  to  supra  spinatus  muscle. 

2',        ,,  infra  spinatus  muscle. 

sj,        ,,  shoulder  joint. 

PT,  Posterior  or  long  thoracic  (external  respiratory  of  Bell)  supplies  serratus 

magnus. 
EAT,  External  anterior  thoracic  supplies  pectoralis  major. 
lAT,  Internal  anterior  thoracic  to  pectoralis  major  and  pectoralis  minor. 

II,  First  intercostal  nerve. 
21,  Second  intercostal  nerve. 

IH,  Intercosto-humeral  joins  nerve  of  Wrisberg. 

AC,  Anterior  cutaneous  nerves  of  the  thorax. 
31,  Third  intercostal  nerve. 

LC,  Lateral  cutaneous  : — 
a.  Anterior  branch. 
p,  Posterior  branch. 
OC,  Outer  cord  of  brachial  plexus. 
PC,  Posterior  cord  ,, 

IC,  Inner  cord. 
MC,  Musculo-cutaneous  nerve. 

4,  Branches  to  coraco-brachialis. 

5,  ,,  biceps. 

5',  ,,  brachialis  anticus. 

6,  Anterior  cutaneous  branch   )  ,     „,  . .j      e  , 

6',  Posterior  cutaneous  branch  |  *«  '^"^^'^  «^^«  °f  ^o^^^^'"' 
IC,  Internal  cutaneous  nerve. 

E,  Anterior  or  external  branch. 

I,  Posterior  or  internal  branch  to  inner  side  of  forearm. 
SIC,  Small  cutaneous  nerve  (nerve  of  Wrisberg)  to  inner  side  of  arm. 
SSS,  Subscapular  nerves  :  — 

21,  Long  subscapular  nerve  to  latissimus  dorsi. 

21',  Muscular  branches  to  subscapularis  and  teres  major. 

21 ,        ,,  ,,  subscapularis. 

C,  Circumflex  Nerve. 

sj',  Branch  to  shoulder  joint. 

8,  Superior  division. 

7,  Cutaneous. 

7',  Muscular  to  deltoid, 
i.  Inferior  division. 

7",  Cutaneous. 

7'",  Muscular  to  teres  minor. 
MS,  Musculo-spiral  Nerve, 

8,      uscular  to  brachialis  anticus.  '  - 

8',  ,,  triceps. 

8",         ,,  anconeus. 

8'",         ,,  supinator  longus. 

8"",        ,,  supinator  brevis. 

8x,        ,,  extensor  carpi  radialis  longior. 

ich,  Internal  cutaneous  branch  to  inner  side  of  arm. 

uec.  Upper  external  cutaneous  branch  to  outer  side  of  arm. 

lee,  Lower  external  cutaneous  branch  to  outer  side  and  back  of  forearm. 

B,  Radial  nerve  cutaneous  to  dorsal  surface  of  thumb  and  two  outer  fingers. 

PI,  Posterior  Interosseous. 

9,  Muscular  branch  to  extensor  carpi  radialis  brevior. 
ossis  metacarpi  pollicis. 


10, 

10", 
10'", 
wj.  Branch  to  wrist  joint. 


primi  internodii  pollicis. 
secundii  internodii  pollicis. 
indicis. 
carpi  ulnaris. 

{digitorum   communis   and   extensor 
minimi  digiti. 


580 


DISEASES  OF  THE  CERVICAL 


"  Fourth  Cervical. — A  similar  movement  of  forearm  and  hand,  flexion 
of  the  forearm,  but  the  upper  arm  is  raised  upwards  and  backwards 
(deltoid,  rhomboid,  supra  and  infra-spinatus,  (teres  minor?),  biceps, 
brachiahs  anticus,  supinator  longus,  extensors  of  wrist  and  fingers, 
diaphragm)."^ 

The   diseases  of  the  brachial  plexus  may  be  divided  into : 
(A),  sensory ;  and  (B),  motor  disorders. 

(A)  Sensory  Disorders  of  the  Brachial  Plexus. 

(1)  Cervico-Brachial  Neuralgia. 

§  287.  Cervico-brachial  neuralgia  includes  all  the  neuralgias 
which  occur  in  nerves  originating  from  the  brachial  plexus,  or 
from  the  posterior  branches  of  the  four  lower  cervical  nerves. 


12', 

12", 

13, 

13', 

13", 

14, 

14', 

M,  Median  Nerve. 

11,  Muscular  branches  to  pronator  radii  teres. 

11',  „  „  flexor  profundus  digitorum. 

11".         ,,  ,,  flexor  longus  poUicis. 

AI,  Anterior  interosseous  branch  to  pronator  quadratus. 

12,  Muscular  branch  to  flexor  carpi  radiahs. 
flexor  sublimis  digitorum, 
palmaris  longus. 
opponens  polUcis, 
abductor  pollicis. 
flexor  brevis  pollicis  (outer  half), 
first  lumbricalis. 
second  lumbricaUs. 

pc,  Palmar  cutaneous  branch. 
D  to  D4,  Digital  cutaneous  branches. 
U,  Ulnar  Nerve. 

e'i,  Branch  to  elbow  joint. 

15,  Muscular  branch  to  flexor  profundus  digitorum  (inner  part). 
15',  „  „  ,,     carpi  ulnaris. 

DC,  Dorsal  cutaneous  branch.     To  dorsal  surface  of  two  inner  hngers. 

p'e',  Palmar  cutaneous  branch. 

c',  communicating  to  median. 

DS  to  D4,  Cutaneous  to  little  finger  and  inner  side  of  ring  finger. 

16,  Muscular  branches  to  palmaris  brevis. 
abductor  minimi  digiti. 
opponens  minimi  digiti. 
flexor  brevis  minimi  digiti. 
fourth  dorsal  interosseous, 
third        „  „ 
second     ,,  „ 
first 

third  palmar  mterosseous. 
second     „  „ 

first         „  „ 

fourth  lumbricalis. 
third  „ 

adductor  pollicis. 
flexor  brevis  pollicis  (inner  half). 

"The  Localisation  of  Atrophic  Paralyses."    Brain,  Vol.  IV. 


16', 

16", 

16'", 

17, 

17', 

17", 

17'", 

18, 

18.', 

18", 

19, 

19', 

20, 

20', 

I  Terrier  (D.) 

1882,  p.  223 

AND  BRACHIAL  PLEXUSES.  581 

Etiology. — The  predisposing  causes  of  cervico-brachial  are  the 
same  as  those  of  cervico-occipital  neuralgia ;  hysteria  and  anaemia 
appear  to  be  specially  frequent  causes  of  this  form  of  neuralgia, 
hence  females  are  more  frequently  affected  by  it  than  males. 

The  most  important  of  the  exciting  causes  of  the  disease  are 
the  various  injuries  to  which  the  upper  extremities  are  so  pecu- 
liarly exposed.  Exposure  to  cold  and  over-exertion  are  also 
frequent  exciting  causes  of  the  disease.  Mr.  James  Salter^  has 
shown  that  cervico-brachial  neuralgia  may  occasionally  originate 
from  reflex  irritation  set  up  by  carious  teeth.  Lead  poisoning 
and  malaria  produce  this  form  of  neuralgia,  and  it  may  be  a 
symptom  of  central  disease,  as  tabes,  hemiplegia,  and  progressive 
muscular  atrophy. 

Symptoms. — The  pain  of  cervico-brachial  neuralgia  is  more 
or  less  continuous,  and  is  of  a  dull,  boring,  or  burning  character, 
interrupted  by  paroxysms  of  lancinating  pains  which  shoot 
through  the  arm  along  the  course  of  the  principal  nerve 
trunks.  The  violent  burning  described  by  Weir  Mitchell,^  under 
the  name  of  "  Causalgia,"  is  often  present  in  the  neuralgias 
which  are  caused  by  gunshot  injuries  of  the  nerves.  The  pain 
often  occurs  in  nocturnal  paroxysms,  which  last  through  the 
night,  and  may  almost  disappear  during  the  day.  A  paroxysm 
may  be  revived  or  aggravated  by  movements  of  the  muscles  of 
the  arm,  such  as  those  involved  in  playing  the  piano,  sewing,  or 
other  manual  operations.  The  pain  is  seldom  limited  to  one 
branch  of  a  nerve ;  it  may  have  its  seat  in  the  upper  arm  or 
forearm,  or  may  extend  into  the  hands  and  fingers,  but  the 
intimate  interweaving  of  the  various  nerve  trunks  in  the 
brachial  plexus  renders  it  difficult  to  determine  what  nerve 
roots  or  branches  of  the  plexus  are  implicated.  It  is  only  when 
the  neuralgia  affects  some  part  near  the  periphery  that  the  pain 
is  limited  to  any  particular  branch  of  the  plexus, 

Painful  Points. — Owing  to  the  numerous  peripheral  anastomoses  of  the 
branches  of  the  nerves,  the  painful  points  are  somewhat  indefinite.  The 
following  have  been  distinguished  by  Valleix,  and  confirmed  by  Dr.  Anstie : 
] ,  An  axillary  point,  corresponding  to  the  brachial  plexus  itself ;    2,  a 

'Salter  (J.).  "Affections  of  the  nervous  system  dependent  on  diseases  of  the 
permanent  teeth."    Guy's  Hospital  Reports,  1867,  p.  88  et  seq. 

*  Mitchell  (S.  Weir).  Injuries  of  nerves  and  their  consequences.  Lond.,  1872, 
p.  272. 


582 


DISEASES  OF  THE  CERVICAL 


scapular  point,  corresponding  to  the  lower  angle  of  the  scapula,  which  is 
difficult  to  explain ;  3,  a  shoulder  point,  which  corresponds  to  the  emergence, 
through  the  deltoid  muscle,  of  the  cutaneous  branches  of  the  circumflex  ; 
4,  a  median-cephalic  point,  at  the  bend  of  the  elbow,  where  a  branch  of  the 


Fig.  74. 


Fig.  75. 


Figs.  74  and  75  (after  Flower).     Cutaneous  Nerves  of  the  Trunk,  Upper  Extremity, 
Sa,  Supra  clavicular  nerve. 
IID,  Second  dorsal. 

PS,  Posterior  branches  of  the  spinal  nerves. 
LI,  Lateral  branches  of  the  intercostal  nerves. 
AI,  Anterior  branches  of  the  intercostal  nerves. 
II,  Iliac  branch  of  ilio-inguinal  nerve. 
I'H',_  Ilio  hypogastric  nerve. 
C,  Circumflex  nerve. 
IH,  Intercosto  humeral. 
W,  Nerve  of  Wrisberg. 

I'CB,  Internal  cutaneous  branch  of  musculo-spiral  nerve. 
ECB,  External  cutaneous  branch  of  musculo-spiral  nerve. 
ICB,  Internal  cutaneous  nerve. 
MC,  Musculo  cutaneous. 
R,  Radial  nerve. 
U,  Ulnar  nerve. 
M,  Median  nerve. 


AND   BRACHIAL   PLEXUSES. 


583 


musculo -cutaneous  nerve  lies  immediately  behind  the  median  -  cephahc 
vein ;  5,  an  external  humeral  point,  about  three  inches  above  the  elbow, 
corresponding  to  the  emergence  of  the  cutaneous  branches  which  the 
musculo-spiral  gives  off  as  it  lies  in  the  groove  of  the  humerus ;  6,  a 
superior  ulnar  point,  corresponding  to  the  course  of  the  ulnar  nerve 
between  the  olecranon  and  the  epitrochlea  ;  7,  an  inferior  ulnar  point, 
where  the  ulnar  nerve  passes  in  front  of  the  annular  ligament  of  the  wrist ; 
8,  a  radial  point,  marking  the  place  where  the  radial  nerve  becomes  super- 
ficial at  the  lower  and  external  aspect  of  the  forearm.  Painful  points 
may  occasionally  be  developed  by  the  side  of  the  lower  cervical  vertebrae, 
corresponding  to  the  posterior  branches  of  the  lower  cervical  nerves. 

Concomitant  symptoms  are  almost  always  present  m  every 
case  of  cervico- brachial  neuralgia.  In  some  cases  a  certain 
amount  of  anaesthesia,  numbness,  and  formication  is  present,  and 
in  other  cases  the  affected  region  of  the  skin  is  so  hypersesthetic 
that  contact  with  the  bed-clothes  is  rendered  unendurable. 
Radiating  pains  are  felt  in  the  region  of  distribution  of  the  cer- 
vical plexus  and  of  the  upper  dorsal  and  intercostal  nerves. 

The  motor  disturbances  consist  of  fibrillary  contractions  and 
twitchings  of  the  muscles  of  the  upper  extremities,  and  in 
aggravated  cases  they  may  be  maintained  in  a  state  of  persistent 
spasm.  In  chronic  cases  particular  muscles  or  groups  of  muscles 
may  be  much  enfeebled  or  even  completely  paralysed,  but  in 
these  the  affection  is  most  probably  a  neuritis  and  not  a  simple 
neuralgia. 

The  vcfcso-mofor  disturbances  con- 
sist at  times  of  coldness  and  pallor, 
and  at  other  times  of  heat  and  red- 
ness of  the  affected  extremity. 

The  trophic  disorders  most 
usually  met  with  are  eruptions 
of  herpes,  but  the  aggravated 
cases  which  are  caused  by  severe 
injuries  of  nerves  are  complicated 
by  pemphigus,  obstinate  ulcers, 
glossy  skin,  and  changes  in  the 
growth  of  the  nails  and  hair. 
In  cervico-brachial  neuralgia  the     _  ,  ,      ^        ,     ^.    ., 

-    ,                                       °  Fig.   76   (after  Krause).     Distrihu- 

State  01  the  heart  and  large  vessels  Hon  of  the  Sensory  Nerves  on  the 

„i  ,  J.     1                n  ■,-,                L   •       ^  Back  of  the  Hand. — r,  radial;  m, 

ought  to  be  carefully  ascertamed.  median  :  and  u,  ulnar  nerve. 


Fig.  76. 


584  DISEASES  OF  THE   CERVICAL 

Diagnosis. — Cervico-brachial  neuralgia  may  be  mistaken  for 
many  kinds  of  painful  affections,  as  muscular  and  articular  rheu- 
matism, diseases  of  bone,  &c.,  and  this  mistake  can  only  be 
avoided  by  a  careful  examination  into  all  the  circumstances 
of  the  case. 

Treatment. — The  treatment  ought  first  to  be  directed  to  the 
removal  of  the  cause  of  the  disease ;  and,  considering  how  fre- 
quently this  form  of  neuralgia  is  caused  by  external  injuries  and 
local  growths,  great  scope  is  afforded  for  surgical  interference. 

Electricity  is  the  most  useful  agent  for  the  treatment  of  the 
neuralgia  as  a  symptom.  The  constant  current  is  to  be  preferred, 
but  generally  the  faradic  current  succeeds  when  the  other  fails. 

Narcotics  must  be  given  in  severe  cases,  and  the  subcuta- 
neous injection  of  morphia  is  generally  the  best,  although  great 
benefit  is  sometimes  obtained  from  the  use  of  belladonna  or 
atropine.  External  applications  are  also  useful,  the  most  gene- 
rally employed  being  liniments  of  chloroform,  and  ointments 
containing  opium,  or  veratria.  The  various  forms  of  counter- 
irritation  may  be  sometimes  employed,  and  Weir  Mitchell  recom- 
mends repeated  vesication  in  the  treatment  of  "  causalgia."  For 
internal  treatment,  quinine,  iron,  and  arsenic  are  the  remedies 
to  be  mainly  relied  upon.  Cold  or  hot  water  treatment,  in  the 
form  of  baths,  shampooing,  and  fomentations,  may  be  employed 
according  as  the  one  or  other  is  found  to  afford  the  greatest 
amount  of  relief. 

Neurectomy  of  mixed  nerves  should  only  be  resorted  to  under 
pressing  necessity,  and  only  when  distinct  evidence  has  been 
obtained  of  the  existence  of  a  peripheral  cause  for  the  neuralgia. 
And  what  is  true  of  neurectomy  in  this  respect  is  applicable  to 
a  still  greater  extent  with  regard  to  amputation  or  resection  as  a 
means  of  obtaining  relief 

(2)  Anaesthesia  in  the  Area  op  Distribution  op  the  Brachial 

Plexus. 

§  288.  In  destroying  lesions  of  the  nerves  of  the  brachial 
plexus  more  or  less  cutaneous  ansesthesia  is  usually  present  along 
with  paralysis  of  the  muscles ;  at  the  same  time  the  extent  of  the 
ansesthesia  does  not  correspond  by  any  means  with  the  anatomical 
distribution  of  the  nerves.   Lesions  of  the  circumflex  nerve  do  not 


AND  BRACHIAL  PLEXUSES. 


581 


give  rise  to  any  very  manifest  disorders  of  sensibility,  but  those 
of  the  musculo-cutaneous  nerve  are  accompanied  by  ansesthesia 
along  the  radial  border  of  the  forearm.  Disease  of  the  musculo- 
spiral  nerve,  when  situated  high  up,  gives  rise  to  ansesthesia  in 
the  areas  of  distribution  of  the  superior  and  inferior  external 
cutaneous  branches ;  but  when  the  lesion  is  situated  low  down, 
the  dorsal  surfaces  of  the  thumb  and  of  the  index  and  half  the 
middle  finger  as  far  as  to  the  second  phalanx  and  the  corre- 
sponding parts  of  the  back  of  the  hand  are  alone  affected. 
Disturbances  of  sensibility  may  be  absent  in  diseases  of  the 
median,  even  when  the  nerve  is  completely  divided  above  the 
wrist,  owing  doubtless  to  the  anastomoses  it  forms  with  the 
other  nerves  of  the  forearm.  If  sensory  disorders  be  present 
they  appear  in  the  lateral  part  of  the  palm  of  the  hand,  on  the 
palmar  aspect  of  the  thumb,  index,  and  middle  fingers,  and  in 
the  ungual  phalanges  on  the  dorsal  aspect  also  {Fig.  76). 
Lesions  of  the  ulnar  nerve  give  rise  to  ansesthesia  of  the  palmar 
aspects  of  the  little  and  half  of  the  ring  finger,  the  corresponding 
part  of  the  palm  of  the  hand,  and  the  dorsal  surfaces  of  the  two 


Fig.  77, 


Figs.  77  and  78  (after  Mitchell).  Dorsal  and  Palmar  Aspects  of  the  Hand  respectively, 
a,  pain  and  touch  lost ;  £,  touch  lost ;  B',  touch  slightly  lessened. 


586  DISEASES   OF  THE   CERVICAL 

ulnar  fingers.  A  very  important  case  is  reported  by  Dr.  Weir 
Mitchell,^  in  which  a  portion  of  the  median  and  of  the  musculo- 
spiral  nerves  were  excised,  at  different  times,  in  a  lady  for  the 
relief  of  intense  brachial  neuralgia,  and  in  which  the  disorders  of 
sensibility  produced  were  carefully  observed.  Towards  the  end 
of  1871,  Dr.  Sapolini,  surgeon  to  the  King  of  Italy,  removed  an 
inch  of  the  musculo-spiral  nerve  in  the  upper  arm.  The  patient 
was  astonished  at  the  slight  degree  of  loss  of  tactile  sensibility 
which  followed  the  operation,  and  the  pain,  which  was  relieved 
at  first,  recurred  eight  days  afterwards.  The  extensor  muscles 
were  paralysed  for  some  time,  but  motor  power  gradually  re- 
turned in  them  about  six  months  after  the  nerve  was  divided, 
and  two  years  after  the  operation  voluntary  power  over  the 
extensors  was  scarcely  impaired.  In  1873,  fifteen  months  after 
the  first  operation,  three-quarters  of  an  inch  of  the  median  nerve 
was,  in  accordance  with  Dr.  Mitchell's  advice,  removed  by  Dr. 
Brintou,  and  in  order  to  prevent  reunion  the  lower  end  of  the 
nerve  was  doubled  upon  itself.  The  distribution  of  the  anaes- 
thesia to  pain  and  touch  observed  at  the  end  of  two  weeks  is 
shown  in  Figs.  77  and  78 ;  and  it  will  be  seen  to  be  very  diffe- 
rent to  that  which  might  be  expected  from  the  supposed 
anatomical  distribution  of  the  nerve.  When  the  patient  was 
examined  nine  months  after  the  operation  the  area  of  anses- 
thesia  had  become  considerably  diminished  on  the  palm,  but 
remained  nearly  the  same  on  the  dorsal  aspect  of  the  hand. 
After  a  time  the  pain  returned  in  the  territory  of  the  musculo- 
spiral  nerve  with  all  its  former  intensity,  and  Dr.  Brinton, 
still  acting  under  Dr.  Mitchell's^  advice,  removed  nearly  three 
inches  of  the  musculo-spiral  nerve  on  a  level  with  Dr.  Sapolini's 
operation,  which  had  been  performed  two  years  and  seven 
months  previously.  The  condition  of  the  sensibility  of  the  skin 
over  the  palmar  and  dorsal  aspects  of  the  hand,  four  weeks  after 
the  operation,  is  represented  in  Figs.  79  and  80  respectively. 
The  little  spot  of  hyperalgesia  over  the  ball  of  the  thumb  offers 
a  curious  phenomenon,  which  is  somewhat  difficult  to  explain. 


1  Mitchell  (S.  Weir).  "Traumatic  neuralgia:  section  of  median  nerve."  The 
American  Journal  of  the  Medical  Sciences,  Vol.  II.,  1874,  p.  17. 

"^  Mitchell  (S.  Weir).  "  Neurotomy."  The  American  Journal  of  the  Medical 
Sciences,  Vol.  I.,  1876,  p.  321. 


AND  BRACHIAL  PLEXUSES. 


587 


The  precautions  taken  to  prevent  reunion  of  the  median,  taken 
along  with  the  fact  that  the  muscles  supplied  by  it  below  the 
point  of  division  remained  permanently  paralysed,  renders  it  ex- 
tremely unlikely  that  its  ends  had  become  joined,  and  no  one  can 
believe  that  the  musculo -spiral  had  become  united  in  four  weeks 
after  three  inches  of  it  had  been  removed,  and  consequently  the 
terminal  branches  of  the  ulnar,  and  a  few  filaments  from  the  in- 
ternal cutaneous  and  musculo -cutaneous  nerves  suffice  to  bestow 
sensibility  upon  the  whole  of  the  palmar  and  dorsal  aspects  of 
the  hand  with  the  exception  of  the  comparatively  small  portions 
which  are  shaded  in  Figs.  79  and  80 ;  even  in  the  areas  most 
deeply  shaded,  and  which  represent  the  regions  of  greatest  anaes- 
thesia, sensation  was  not  entirely  abolished,  inasmuch  as  the 
prick  of  a  needle  was  still  felt. 

Two  other  instructive   cases   with   regard  to  the   effects  of 
resection  of  nerves  upon  the  sensibility  are  mentioned  by  Dr. 


Figs.  79  and  80  (after  Mitchell).  Dorsal  and  Palmar  Aspects  of  the  Hand.  —The 
light  shading  indicates  the  area  in  which  tactile  sensibility  was  diminished ;  the 
deep  shading  the  area  in  which  it  was  lost.  The  marks  ( >  < )  indicate  the 
appreciation  of  separate  points.  A  single  ( v )  mark  indicates  that  the  points  are 
not  felt  as  separate.  The  absence  of  the  ( v )  mark  indicates  complete  loss  of 
tactile  sensibility.     H,  a  small  area  in  which  there  is  hyperalgesia  of  the  skin. 


588  DISEASES   OF  THE   CERVICAL 

Mitchell.  Id  one  of  them  Dr.  Hodge  removed  an  inch  of  the 
digital  branches  of  the  ulnar  and  median  nerves  to  the  fourth 
finger.  The  nerves  were  removed  in  their  course  along  the 
whole  of  the  second  phalanx,  and  yet  sensibility  remained 
normal  except  over  the  surface  of  the  ungual  phalanx.  In  the 
second  case  Dr.  Hodge  removed  two  inches  of  the  radial  nerve 
in  the  back  of  the  forearm.  The  pain  returned  after  some 
weeks,  and  three  inches  of  the  nerve,  which  had  become  united, 
was  then  removed,  and  the  ends  of  the  distal  extremity  were 
folded  back  so  as  to  prevent  reunion.  The  distribution  of  the 
anaesthesia  in  the  dorsal  aspect  of  the  hand  is  represented  in 
Fig.  81  as  it  was  found  two  weeks  after  the  operation.  Arloing 
and  Tripier^  have  found  that,  so  long  as  a  single  nerve  is  left 
undivided,  the  whole  of  the  paw  of  the  dog  retains  some  degree 
of  sensibility.  This  conclusion,  as  remarked  by  Dr.  Weir 
Mitchell,  appears  to  be  more  or  less  applicable  to  man. 

Our  data  for  determiniog  the  respective  connections  of  the 
sensory  nerves  of  the  upper  extremity  with  the  cervical  portion 

Fia.  81. 


Fig.  81  (after  Mitchell).  The  Dorsal  Aspect  of  the  Hand  Tioo  Weeks  after  Resection  of 
the  Radial  Nerve.— A.  B  and  A  0,  the  length  of  the  portion  removed.  The 
light  shading  represents  the  area  in  which  tactile  sensibility  was  diminished  ; 
the  deep  shading  the  area  in  which  it  was  lost. 


'  Arloing  et  Tripier  (L^on).     "Recherches  sur  la  sensibilite  des  teguments  et 
des  nerfs  de  la  main."    Archives  de  Physiologie,  Tome  II.,  1869,  pp.  33  and  307. 


AND  BRACHIAL  PLEXUSES. 


589 


of  the  spinal  cord  are  as  yet  very  scanty.  In  the  cases  of  com- 
bined paralysis  of  the  deltoid,  biceps,  brachialis  anticus,  and 
supinator  longus  muscles,  first  described  by  Erb,  and  which  are 
most  probably  caused  by  a  destructive  lesion  of  the  root  derived 
from  the  fifth  cervical  nerve,  formication  and  numbness  in  the 
outer  surface  of  the  arm  and  forearm,  as  well  as  in  the  thumb 
and  index  finger,  have  been  described  by  patients,^  but  the  sen- 
sory disorders  soon  disappear  in  such  cases.  In  a  case  at  present 
under  my  care,  in  which  there  are  strong  grounds  for  believing 
that,  so  far  at  least  as  the  motor  fibres  are  concerned,  the  roots 
derived  from  the  fifth,  sixth,  seventh,  and  eighth  cervical,  and  the 
first  dorsal  nerves  of  the  left  side  are  ruptured,  the  only  part  of 


Fig.  82. 


Fig.  83. 


> 

\ 


vV 


Figs.  82  and  83. — Posterior  and  anterior  aspect  respectively  of  the  arm  in  a  case  of 
rupture  of  the  brachial  plexus,  the  shaded  area  showing  the  distribution  of  the 
ansesthesia.  By  an  oversight  the  right  arm  is  represented  as  being  affected 
instead  of  the  left. 


1  See  Hoedemaker.    Arch,  fiir  Psychiat.,  Bd.  IX.,  1878-9,  p.  738. 


590  DISEASES  OF  THE  CERVICAL 

the  skin  of  the  upper  arm  which  is  ansBsthetic  is  the  middle  third 
of  the  anterior  aspect  of  the  inferior  half  of  the  arm,  while 
posteriorly  the  region  of  absolute  anaesthesia  does  not  even  reach 
as  high  as  the  elbow.  The  distribution  of  complete  anaesthesia 
six  months  after  the  accident  is  indicated  by  the  shaded  portions 
in  Figs.  82  and  83,  although  about  an  inch  of  the  upper  limits 
of  even  this  region  is  not  absolutely  insensible  to  the  prick  of 
a  pin.  The  portion  of  the  skin  of  the  arm  above  the  shaded 
areas  in  Figs.  82  and  83  is  almost  as  sensitive  to  the  prick 
of  a  pin  and  to  touch  as  the  corresponding  parts  on  the  right 
side,  although  the  power  of  appreciating  separate  points  is 
diminished  in  the  former,  as  compared  with  the  latter,  in  the 
proportion  of  3|  to  5  mm.,  on  an  average  of  many  observations. 
The  prick  of  a  pin,  and  pinching  of  the  skin,  is  more  painful  on  the 
left  than  the  right  arm,  except  in  the  area  which  is  completely 
anaesthetic.  The  inner  aspect  of  the  upper  arm  is  doubtless 
supplied  by  the  intercosto-humeral  nerve,  which  is  derived  from 
the  second  dorsal  nerve,  and  is  not  implicated  in  the  lesion ;  but 
if  it  be  true  that  the  sensory  as  well  as  the  motor  fibres  of  the 
fifth  cervical  nerve  are  ruptured,  then  the  skin  of  the  upper 
part  of  the  arm  anteriorly,  and  that  of  almost  the  whole 
of  the  posterior  and  outer  aspects  of  the  arm,  must  be  in- 

FiG.  84. 


Fig.  84  (after  Maury  and  Duhring). — The  line  aaa,  on  the  outer  surface  of  the  arm, 
marks  the  boundary  above  and  outside  of  which  sensation  is  preserved.  The 
dotted  line  b  b  marks  the  same  for  the  inner  surface  of  the  arm. 


AND   BRACHIAL  PLEXUSES,  591 

nervated  by  sensory  nerves  from  the  supra-clavicular  branches 
of  the  cervical  plexus  and  the  communicating  branch  to  the 
plexus  from  the  fourth  nerve.  In  a  case  of  excision  of 
the  brachial  plexus  by  Maury  and  Duhring^  for  the  relief  of 
painful  neuroma  of  the  skin,  the  sensations  of  pain  and  touch 
were  absent,  six  months  after  the  operation,  over  the  whole  of 
the  skin  of  the  forearm  and  hand,  as  well  as  in  that  of  the  anterior 
aspect  of  the  upper  arm,  as  represented  by  the  area  included 
within  the  lines  a  a  and  &  6  in  Fig.  84.  The  whole  of  the  pos- 
terior, external,  and  internal  surfaces  of  the  arm  were  sensitive  to 
touch  and  to  the  prick  of  a  needle,  the  sensation  being  more  acute 
in  the  superior  than  the  inferior  part  of  the  arm.  It  will  be  seen 
that  in  this  case  a  rather  larger  portion  of  the  skin  of  the  anterior 
surface  of  the  arm  was  rendered  anaesthetic  than  in  my  case  of 
rupture  of  the  brachial  plexus;  in  section  of  the  plexus  the 
communicating  branch  from  the  fourth  cervical  nerve  to  the 
plexus  would  be  divided,  but  it  was  likely  to  have  been  spared 
in  the  case  of  rupture.  In  a  case  of  hsematomyelia  recorded 
by  myself,^  in  which  the  lesion  occupied  most  probably  the 
right  lateral  half  of  the  spinal  cord,  and  extended  from  the 
level  of  the  ninth  dorsal  up  to  that  of  the  eighth  cervical 
nerve  inclusive,  the  distribution  of  the  anaesthesia  anteriorly  is 
represented  in  Fig.  85  ;  it  may  also  be  taken  to  represent  its 
distribution  posteriorly,  inasmuch  as  a  strip  of  skin  along  the 
whole  of  the  inner  border  of  the  arm  and  forearm,  and  the 
inner  half  of  the  dorsal  aspect  of  the  hand  with  two-and-a-half 
fingers  were  anaesthetic.  The  anaesthesia  was  not  absolute,  as 
the  patient  could  feel  the  prick  of  a  pin,  and  could  localise 
touch  fairly  well,  but  he  could  bear  strong  pinching  of 
the  affected  portions  of  skin  without  evidence  of  pain.  The 
area  of  anassthetic  skin  in  the  upper  extremity  is  supplied  by 
the  intercosto-humeral,  the  nerve  of  Wrisberg,  the  internal 
cutaneous  and  the  terminal  branches  of  the  ulnar  nerve, 
although  it  is  not  strictly  limited  to  the  distribution  of  these 
nerves.  In  a  case  of  pachymeningitis  cervicalis  at  present 
under  my  care,  in  which  the  lesion  is  situated  opposite  the 

'  Maury  and  Duhring.  "  Case  of  exaection  of  the  brachial  plexus  of  nerves  for 
the  relief  of  painful  neuroma  of  the  skin."  The  American  Journal  of  the  Medical 
Sciences,  Vol.  II.,  1874,  p.  29. 

""  Ross  (J.).    The  Practitioner,  Sept.,  1882,  p.  172. 


592 


DISEASES  OF  THE  CERVICAL 


last  cervical  and  first  dorsal  vertebras,  the  distribution  of  the 
anaesthesia  (incomplete)  is  represented  by  the  shaded  portion  in 
Fig.  86.  The  anaesthesia  of  the  lower  extremities  and  trunk 
is  doubtless  caused  by  interruption  of  the  sensory  conducting 
paths  at  the  level  of  the  lesion  in  their  ascent  towards  the 
brain,  but  the  anaesthesia  of  the  upper  extremities  is  most 
probably  produced  by  implication  of  the  posterior  roots  of  the 
eighth  cervical  and  first  and  second  dorsal  nerves. 

Treatment. — The  anaesthesia  itself  does  not  demand  separate 
treatment,  which  must  be  directed  against  the  primary  lesion 
and  the  co-existing  muscular  paralysis. 


Fig.  85. 


Fig.  86. 


Fig.  85, — The  shaded  portion  shows  the 
distribution  of  anaesthesia  anteriorly 
in  a  case  of  h^matomyelia,  in  which 
the  upper  limit  of  the  lesion  was  on  a 
level  with  the  eighth  cervical  nerve. 


Fig.  86.— The  shaded  portion  shows  the 
distribution  of  anaesthesia  in  a  case  of 
cervical  pachjnneningitis,  in  which  the 
lesion  was  situated  on  a  level  with  the 
eighth  cervical  and  first  and  second 
dorsal  nerves. 


AND  BRACHIAL  PLEXUSES. 


593 


(B)  Motor  Disorders  of  the  Brachial  Plexus. 

The  motor  disorders  of  the  brachial  plexus  may  be  sub-divided 
into  (1)  spasm,  and  (2)  paralysis  of  the  muscles  supplied  by  it. 

(1)  Spasm  of  the  Muscles  supplied  by  the  Brachial  Plexus. 

§  289.  The  spasmodic  affections  of  the  brachial  plexus  may  be 
sub-divided  into  (a)  spasm  of  the  muscles  of  the  neck  and  trunk, 
and  (6)  of  those  of  the  upper  extremity. 


Fig.  87. 


(a)  Spasm  of  Special  Muscles  and  Groups  of  Muscles  of  the 
Neck  and  Trunk. 

(i.)  Spasm  of  the  Rhomhoidei  manifests  itself  by  the  peculiar 
position  of  the  scapula.  Its  inner  border  assumes  an  oblique 
position  from  above  downwards,  and  from  without  inwards, 
the  lower  angle  being  drawn  upwards  and  approximated  to  the 
vertebral  column.  The  muscle 
can  be  felt  as  a  firm  swelling 
between  the  spinal  column  and 
scapula.  This  affection  is  dis- 
tinguished from  paralysis  of 
the  serratus  magnus  by  the 
fact  that  the  internal  border  of 
the  scapula  is  not  lifted  away 
from  the  chest,  the  shoulder  is 
not  depressed,  and  distinct  re- 
sistance is  experienced  from 
the  contracted  muscle  when 
an  attempt  is  made  to  raise 
the  arm  to  a  vertical  position. 
Tonic  spasm  or  contracture  of 
this  muscle  has  hitherto  alone 
been  observed. 

(ii.)  Spasm  of  the  Levator 
Anguli  Scapulce. — The  upper 
and  inner  angle  of  the  scapula 
is  strongly  elevated  in  this 
affection;  the  head  is  slightly 
VOL.  I.  MM 


/:^'i'  / 


Fig.  87  (Duchenne),  Contraction  of  Ehom- 
boid  Muscles.  —  A,  Levator  scapulae ; 
B,  Eetracted  rhomboid ;  C,  Fibres  of 
serratus  magnus;  D,  Abnormal  posi- 
tion of  the  inferior  angle  of  the  scapula; 
E,  Inferior  angle  on  the  healthy  side. 


594  DISEASES   OF  THE  CERVICAL 

inclined  to  the  same  side ;  the  shoulder  is  drawn  somewhat- 
forwards;  the  supra-clavicular  fossa  is  increased  in  depth;  and 
the  contracted  muscle  projects  distinctly  beneath  the  anterior 
border  of  the  trapezius,  which  can  easily  be  isolated  from  it  by 
faradisation.  It  occurs  in  the  form  of  a  tonic  contracture  in 
combination  with  spasm  of  the  rhomboidei  or  of  the  trapezius. 

(iii.)  Spasm  of  the  serratus  magnus,  of  the  latissiTnus  dorsi  of 
the  teres  major  and  nfiinor,  of  the  supra  and  infraspinati,  of 
the  suh- scapular  is,  or  of  the  pectoralis  m^ajor  is  rare ;  it  may  be 
readily  recognised  by  the  position  assumed  by  the  scapula  and 
arm,  and  the  particular  interference  with  their  movements,  along 
with  the  hardness  and  fulness  felt  over  the  affected  muscle.  A 
comparison  of  the  deformity  produced  by  faradisation  of  the  cor- 
responding muscle  of  the  opposite  side  greatly  aids  the  diagnosis. 

(6)  Spasm  of  the  Muscles  of  the  Upper  Extremity. 

(i.)  Spasm  of  the  Muscles  supplied  by  the  Circumflex  Nerve. 
The  circumflex  nerve  supplies  the  deltoid  and  teres  minor 
muscles,  and  gives  branches  to  the  skin  of  the  upper  arm  and 
shoulder  joint.  In  the  tonic  form  of  this  affection  the  arm  is 
held  out  from  the  body,  and  is  directed  backwards  in  cases  where 
the  posterior  fibres  of  the  deltoid  and  the  teres  minor  are 
affected.  The  lower  angle  of  the  scapula  is  pressed  backwards 
towards  the  vertebral  column,  as  in  paralysis  of  the  serratus 
magnus,^  In  cases  of  clonic  spasm  of  the  deltoid,  the  arm  is 
thrown  upwards  and  moved  convulsively  in  various  directions ; 
other  muscles  are  usually  implicated. 

(ii.)  Spasm  of  the  Muscles  supplied  hy  the  Musculo- Cutaneous 
Nerve. — The  muscles  supplied  by  the  musculo-cutaneous  nerve 
are  the  coraco-braehialis,  the  biceps,  and  the  brachialis  anticus, 
but  the  last  receives  additional  branches  from  the  musculo- 
spiral  nerve.  The  musculo-cutaneous  nerve  passes  through  the 
coraco-braehialis  muscle,  and  is  then  found  in  the  interval 
between  that  muscle  and  the  biceps,  or  further  outwards 
between  the  two  heads  of  the  biceps.  Spasm  of  the  muscles 
supplied  by  this  nerve  causes  strong  flexion  of  the  forearm, 

(iii.)  Spasm  of  the  Muscles  supplied  hy  the  Musculo-Spiral 

'  Duchenne.    L'el^ctrisation  localis^e.    1872.    p.  961. 


AND  BKACHTAL  PLEXUSES. 


595 


Fig.  88. 


Nerve. — The  musculo-spiral  nerve  supplies  the  triceps,  anconeus, 
a  small  part  of  the  brachialis  anticus,  and  all  the  extensor  and 
supinator  muscles  of  the  forearm.  When  the  muscles  supplied 
by  the  musculo-spiral  nerve  are  in  a  state  of  spasm,  the  forearm 
is  extended  upon  the  arm  and  the  hand  upon  the  forearm ;  the 
fingers  are  extended  at  the  metacarpo-phalangeal  articulations, 
and  the  thumb  at  both  the  metacarpo-phalangeal  and  phalangeal 
articulations,  and  the  forearm  is  also  supinated. 

(iv.)  Spasm  of  the  Mus- 
cles supplied  by  the  Median 
Nerve. — The  median  nerve 
supplies  the  pronators,  the 
flexor  carpi  radialis,  the  flexor 
digitorum  sublimis,  the  ra- 
dial half  of  the  flexor  pro- 
fundus digitorum,  the  flexor 
longus  pollicis,  two  outer 
lumbicrales,  and  the  small 
muscles  of  the  ball  of  the 
thumb,  with  the  exception  of 
the  adductor  and  the  ulnar 
head  of  the  flexor  brevis  pol- 
licis. When  the  muscles  sup- 
plied by  the  median  nerve 
are  in  a  state  of  spasm  the 
forearm  is  strongly  pronated, 
the  hand  is  bent  towards  the 
radial  side;  the  fingers  are 
flexed  ;  and  there  is  opposi- 
tion of  the  thumb. 

Spasm  of  the  muscles  of 
the  hand  supplied  by  the 
median  produces  opposition 
of  the  thumb,  with  approxi- 
mation and  slight  flexion  of 
the  first  phalanges  of  the 
index  and  middle  fingers, 

(v.)  Spasm  of  the  Muscles 
supplied  by  the  Ulnar  Nerve. 


Fig.  88.  Masdes  oftlie  IIand{irom  Wilson). 

1,  Annular  ligament. 

2,  2,  Origin  and  insertion  of  the  abductor 

pollicis  muscle. 

3,  Opponens  pollicis. 

4,  Superficial  portion  of  the  flexor  brevis 

pollicis. 

5,  Deep  portion  of  the  flexor  brevis  pollicis. 

6,  Adductor  pollicis. 

7,  7,  The  lumbricales  muscles,  arising  from 

the  deep  flexor  tendons,  upon  which 
the  figures  are  placed.  The  tendons 
of  the  flexor  sublimis  have  been  re- 
moved. 

8,  Insertion  of  one  of  the  tendons  of  the 

deep  flexor. 

9,  The  tendon  of  the  flexor  longus  pollicis, 

passing  between  the  two  portions  of 
the  flexor  brevis  to  the  last  phalanx. 

10,  Abductor  minimi  digiti. 

11,  Flexor  brevis  minimi  digiti. 

12,  Pisiform  bone. 

13,  First  dorsal  interosseous  muscle,   the 

abductor  indicia. 


596 


DISEASES   OF  THE   CERVICAL 


The  ulnar  nerve  innervates  the  flexor  carpi  ulnaris,  the  ulnar 
half  of  the  flexor  profundus  digitorum,  all  the  muscles  of  the 
hypothenar  eminence,  together  with  the  palmaris  brevis,  all  the 
interossei,  the  two  ulnar  lumbricales,  the  adductor  pollicis,  and 
the  inner  head  of  the  flexor  brevis  pollicis.     The  actions  of  the 

Fig.  89. 


Fig.  89.  Attachment  of  an  Interosseous  Muscle  (from  Duchenne). 

a,  Interosseous  muscle. 

b,  Attachment  to  base  of  first  phalanx. 

c,  Slip  passing  forward  to  id)  side  of  extensor  tendon. 
e,  Central  portion  of  extensor  tendon. 

interossei  in  the  movements  of  the  fingers  have  been  carefully 
investigated  by  Duchenne,^  and  are  so  important  as  to  deserve 
special  mention.  The  three  palmar  interossei  are  arranged  as 
adductors  to  and  the  four  dorsal  as  abductors  of  the  fingers  from 
an  imaginary  line  drawn  through  the  long  or  middle  finger. 
The  insertion  of  the  interossei  into  the  base  of  the  first  phalanx 


Fig.  90,  Insertion  of  Muscles  of  Thumb  (from  Duchenne), 
a,  Abductor  pollicis. 
6,  Opponens  pollicis. 

c,  Outer  head  of  flexor  brevia, 

d,  Tendon  of  extensor  secundi  inlernodii. 

e,  Tendinous  expansion  of  flexor  brevis  joining  tendon  of  extensor, 

>  Duchenne.    L'electrisation  localise'e.     1872.     p.  967. 


AND  BRACHIAL   PLEXUSES.  597 

enables  them  to  act  as  flexors  at  the  metacarpo-phalangeal  joint, 
whilst  giving  lateral  movements  to  the  fingers  to  which  they  are 
attached.  The  slip  {Fig.  89,  d)  sent  forward  to  join  the  extensor 
tendons  extends  the  second  and  third  phalanges.  The  interossei, 
therefore,  produce  flexion  at  the  first  and  extension  at  the 
second  and  third  phalanges,  and  also  assist  both  to  adduct  and 
abduct  the  fingers  in  relation  to  the  middle  line  of  the  hand. 
The  lumbricales  act  with  the  interossei  as  flexors  of  the  first  and 
extensors  of  the  second  and  third  phalanges.  The  small  muscles 
of  the  thumb  act  in  a  similar  manner.  The  two  heads  of  the 
flexor  brevis  pollicis  are  inserted  into  the  sides  of  the  base  of 
the  first  phalanx  of  the  thumb,  sending  slips  forward  to  join  the 
tendons  of  the  extensor  secundi  internodii  pollicis  on  the  back 
of  the  first  phalanx  {Fig.  90,  e).  This  arrangement  enables  the 
small  muscles  of  the  thumb  to  extend  the  second  phalanx,  whilst 
acting  on  the  first  in  the  direction  implied  by  their  several  names. 
In  spasm  of  the  muscles  supplied  by 
the  ulnar  nerve  the  hand  is  rendered  ' 

concave  ;  the  thumb  is  adducted  ;  the 
little  finger  is  strongly  flexed  and  op- 
posed; and  the  remaining  fingers  are 
moderately  flexed  at  the  metacarpo- 
phalangeal, and  extended  at  the  pha- 
langeal articulations.  The  position  ^^^^  oMafter  Gowers).  Posi- 
assumed  by  the  hand  in  spasm  of  the        of  the  Hand  in  apasm  of  the 

^  /  ^    '-     ^  Interosseous  Muscles. 

interossei  is  represented  in  Fig.  91. 

(vi.)  Spasms  of  the  'inuscles  of  the  arms  occur  in  various  modes 
and  combinations.  If  the  electrode  of  afaradic  current  be  placed 
at  the  external  edge  of  the  stemo-mastoid  muscle  on  a  level 
with  the  transverse  process  of  the  sixth  cervical  vertebra,  the 
deltoid,  biceps,  coraco-brachialis,  and  the  long  and  short  supinator 
muscles  will  enter  into  contraction.  These  muscles  are  supplied 
by  the  musculo-cutaneous,  circumflex,  and  musculo -spiral  nerves; 
but  all  the  fibres  which  supply  the  muscles  are  found  in  the 
fifth  cervical  root.  This  is  an  important  consideration,  inasmuch 
as  combined  paralysis  of  these  muscles  is  not  unfrequently 
observed.  Alcoholic  tremor  and  that  of  paralysis  agitans  are 
sometimes  limited  to  the  upper  extremities.  Unilateral  epilepsy 
is  not  unfrequently  ushered  in  by  a  convulsive  aura  of  one  arm. 


598  DISEASES   OF   THE  CERVICAL 

The  spasmodic  movements  which  have  been  described  under  the 
names  of  athetosis  and  post  hemiplegic  chorea,  and  which  are 
usually  limited  to  the  haod  and  forearm,  will  be  subsequently- 
described.  Weir  Mitchell  has  described  spasmodic  movements 
in  stumps  left  after  amputation  of  the  arm  ;  they  caused  con- 
stant movement  of  the  stump,  and  were  regarded  by  him  as  of 
reflex  origin. 

The  causes  of  spasm  of  the  muscles  of  the  arm  may  be  peri- 
pheral or  central,  and  it  may  be  due  to  rheumatism  or  to  some 
kind  of  reflex  action ;  in  some  cases  spasms  occur  in  the  absence 
of  any  recognisable  cause.  The  diagnosis  and  prognosis  must  be 
based  on  general  principles  and  on  a  thorough  examination  of  the 
patient,  and  upon  the  seat,  causes,  and  duration  of  the  disease. 

Treatment. — The  treatment  of  spasm  of  these  muscles  is  the 
same  as  for  spasms  of  muscles  in  general.  Duchenne  recom- 
mends in  cases  of  contracture  faradisation  of  the  antagonist 
muscles,  and  cutaneous  faradisation  in  rheumatic  cases  of  recent 
origin. 

(vii.)  Writers'  Cramp. 
(  Oraphospasmus — Mogigraphia.) 

§  290.  Pianists'  Cram^p,  Telegraphists'  Cramp,  Tailors' Cramp, 
Milkers'  Cramp,  &g. — Writers'  cramp  is  only  one  of  a  large  group 
of  affections  which  have  been  called  professional  hyperkineses. 
This  name  has  been  given  to  these  affections  because  the 
spasmodic  movements  always  affect  muscles  engaged  in  delicate 
associated  and  acquired  actions,  such  as  those  required  for 
writing,  pianoforte  playing,  sewing,  &c. 

Etiology. — Writers'  spasm  is  met  with  most  frequently  in 
men.  The  reason  of  the  comparative  immunity  of  women  is 
probably  that  they  are  not  so  often  called  upon  to  over-exert 
themselves  in  writing  as  men.  Pianoforte  players'  spasm,  on 
the  other  hand,  occurs  more  frequently  in  women  than  in  men. 
Writers'  cramp  is  often  inherited,  or  several  members  of  a  family 
may  become  affected  by  it.  The  main  cause  of  the  disease  is  ex- 
cessive writing,  hence  it  is  most  frequently  observed  in  writers, 
secretaries,  clerks,  and  merchants. 

The  spasm  may  occasionally  be  caused  by  exposure  to  cold, 
injuries  of  nerves  or  muscles,  and  foreign  bodies  in  the  fingers, 


AND   BRACHIAL   PLEXUSES.  599 

or  it  may  be  caused  in  a  reflex  manner  by  periostitis  of  the 
external  condyle  of  the  humerus.  In  some  cases  a  slight  injury^ 
of  one  of  the  fingers  is  the  starting  point  of  the  disease,  and  at 
other  times  the  spasms  may  be  caused  by  centric  disease  or 
neuritis  of  one  or  other  of  the  nerve  trunks  of  the  forearm,  but 
such  cases  do  not  strictly  belong  to  true  writers'  spasm. 

Symptoms. — The  disturbances  of  movement  are  at  first  slight, 
and  may  only  amount  to  a  sensation  of  great  weariness  when  the 
act  of  writing  is  long  continued.  After  a  time  the  symptoms 
become  more  marked,  and  make  their  appearance  soon  after  the 
patient  begins  to  write,  or  even  immediately  the  pen  is  taken  in 
the  hand. 

Benedikt^  describes  three  varieties  of  writers'  cramp  ;  namely, 
(1)  the  spastic,  (2)  the  tremulous,  and  (3)  the  paralytic  form. 

(1)  In  the  spastic  form  of  the  disease,  tonic  or  clonic  spasms 
of  one  or  of  several  of  the  muscles  occur.  These  spasms  are  at 
first  limited  to  particular  fingers,  and  cause  an  irregular  stroke  in 
the  writing.  The  patient  cannot  write  while  holding  his  pen  in 
the  usual  position,  but  he  can  do  so  tolerably  well  by  holding  it 
in  a  new  and  more  or  less  grotesque  manner  (Poore).  After  a 
time  the  spasms  become  stronger,  and  are  generally  tonic  in 
character ;  the  thumb  and  first  finger  may  be  suddenly  extended, 
so  that  the  pen  drops,  or  there  is  a  spasmodic  action  of  the 
opponens  poUicis  with  abduction  and  flexion  of  the  index  finger, 
and  the  pen  is  thus  rapidly  moved  away  from  the  paper.  At 
other  times  there  is  a  spasmodic  flexion  of  the  first  three  fingers, 
which  then  become  pressed  tightly  against  the  pen,  so  that  it 
cannot  be  moved  further  onwards ;  or  there  may  be  movements 
of  pronation  and  supination^  in  the  forearm,  and  the  pen  is 
raised  from  the  paper,  and  moved  backwards  and  forwards  in  the 
most  irregular  manner.  The  faradic  contractility  of  the  affected 
muscles  is  sometimes  increased,  and  at  other  times  diminished, 
the  former  probably  indicating  an  early,  and  the  latter  a  late 
stage  of  the  affection.* 

1  Valleroiax  (H.).  "Writers'  Cramp."  TTie  Medical  Times  and  Gazette, 
Vol.  II.,  1S53,  p.  274. 

-Benedikt  (Moritz).     Elektrotherapie.     Wien,  1863.     p.  162. 

^  Buzzard  (T.).  "  Two  cases  of  impaired  writing  power."  The  Practitioner, 
Tol.  IX.,  1S72,  p.  65. 

■'Poore  (G-.  V.).  "An  analysis  of  seventy-five  cases  of  '  Writers' cramp,'  and 
impaired  writing  power."    Medico-Chir.  Transactions,  Vol.  LXI.,  1878,  p.  111. 


600  DISEASES  OF  THE  CERVICAL 

(2)  In  the  tremulous  form  of  the  disease,  the  hand  and  fore- 
arm, or  even  the  whole  arm,  become  the  subjects  of  well-marked 
tremors  on  any  attempt  at  writing  being  made,  so  that  the  pen 
only  makes  undulating  or  angular  strokes,  and  the  writing  be- 
comes completely  illegible. 

The  patient  adopts  many  expedients  to  prevent  the  occurrence 
or  to  counteract  the  effects  of  the  spasms ;  but,  in  spite  of  all,  the 
handwriting,  when  writing  is  possible,  becomes  completely  altered 
in  character.  The  strokes  are  coarse,  imperfect,  and  unequal,  and 
numerous  irregularities  and  false  strokes  are  to  be  observed ; 
in  the  highest  degrees  of  the  affection  the  writing  becomes  a 
mass  of  undulating  and  zigzag  strokes,  and  wholly  illegible. 

(3)  The  paralytic  form  offers  a  great  contrast  to  the  spastic 
and  tremulous  varieties.  In  this  form  great  fatigue  and  weak- 
ness of  the  hand  and  forearm  are  experienced  when  the  patient 
attempts  to  write,  but  as  soon  as  the  pen  is  laid  down  the 
feeling  of  weakness  and  exhaustion  disappears,  to  reappear  when 
it  is  taken  up  again.  It  is  generally  confined  to  the  flexors,  or 
to  the  extensors  muscles. 

In  those  who  suffer  from  writers'  cramp  the  movements  re- 
quisite for  sewing,  pianoforte  playing,  embroidery,  buttoning-up 
the  clothes,  and  all  actions  requiring  delicate  manipulation  are 
also  impaired ;  and  if  the  patient  has  learned  to  write  with  his 
left  hand,  the  spasm,  to  his  great  disappointment,  frequently 
extends  to  it  also.^ 

The  most  common  sensory  disturbances  are  feelings  of  weari- 
ness and  formication^  in  the  affected  extremity.  The  pain  fre- 
quently extends  to  the  shoulder  and  back,  and  some  of  the 
spinous  processes  of  the  cervical  and  dorsal  vertebrae  may  be 
sensitive  to  pressure.  A  feeling  of  numbness  is  sometimes  com- 
plained of,  but  anaesthesia  or  hypersestbesia  is  rare,  and  it  is  only 
very  occasionally  that  the  presence  of  pressure  points  has  been 
ascertained ;  in  these  cases  it  is  probable  that  neuritis  has  been 
present.  The  most  common  sensory  disorder,  according  to 
Hasse,^  is  an  undefined  feeling  of  straining  and  fatigue,  a  sen- 

•  Brown-S^quard.  "  Case  of  writers'  palsy."  Medical  Times  and  Gazette, 
Vol.  II.,  1860,  p.  532. 

^  Solly.  "Clinical  lectures  on  scriveners' palsy."  The  Lancet,  Vol.  II.,  1864,  p,  709. 

^  Hasse.  Virchow's  Handbuch  der  Speciellen  Pathol,  und  Therap.  Bd.  IV,, 
Abth.  I.,  1855,  p.  145. 


AND  BRACHIAL  PLEXUSES.  601 

sation  of  pressure  in  the  affected  muscles,  a  painful  drawing  of 
the  nerves  in  the  direction  of  the  trunk,  or  a  feeling  of  coldness 
in  the  whole  arm. 

Other  spasmodic  disturbances  are  not  unfrequently  associated 
with  writers'  cramp.  Amongst  the  most  frequent  of  them  may 
be  mentioned  strabismus,  stammering,  and  spasm  of  the  face, 
throat,  and  other  parts  of  the  body,  while  weakness  of  the 
lower  extremities  with  tremors  occasionally  occurs.  In  addition 
to  the  mental  depression  caused  by  failure  of  the  hand,  the 
patients  are  often  of  an  anxious  and  excitable  disposition,  and, 
as  Poore  remarks,  their  writing  is  worse  in  the  presence  of  spec- 
tators, or  when  the  matter  to  be  written  is  of  much  importance. 

A  few  of  the  other  professional  hyperkineses  may  be  briefly 
mentioned. 

Pianoforte  Players'  Spasm  is  not  of  uncommon  occmTence  in  pro- 
fessional players,  especially  women.  It  presents  the  same  features  as 
writers'  spasm,  and  requires  no  separate  description. 

Telegraphists'  Cramp  has  been  described  by  Onimus^  as  occurring  in 
France,  but  I  am  not  aware  that, it  has  been  met  with  in  this  country. 
The  instrument  used  was  Morse's  machine,  in  which  the  letters  are  repre- 
sented by  an  association  of  dashes  and  dots.  In  one  case  described  by 
him  the  formation  of  all  dots  and  dashes  became  after  some  time  impossible 
with  the  hand  held  in  the  ordinary  position,  and  the  patient  endeavoured 
to  act  on  the  manipulator  by  the  thumb  alone,  and  was  able  for  nearly  two 
years  to  transmit  the  despatches  in  this  way. 

Violin  Players'  Spasm  sometimes  occurs  in  the  left,  sometimes  in  the 
right  hand,  either  in  the  form  of  painful  exhaustion  and  stiffness,  or  as 
convulsive  sj)asm  of  some  of  the  muscles  of  the  head,  arm,  or  shoulder. 
It  renders  playing  impossible. 

Tailors'  and  Shoemakers'  Spasms  are  of  the  same  kind  as  the  other 
professional  spasms,  and  as  soon  as  the  patient  begins  to  work,  tonic  or 
clonic  spasms  or  functional  debility  of  the  muscles  of  the  hand  and  arm  are 
experienced. 

The  varieties  of  these  spasms  might  be  largely  increased.  Indeed  they 
may  occur  in  any  avocation  requiring  the  constant  associated  action  of 
certain  groups  of  muscles.  Such  spasmodic  muscular  movements  have 
already  been  observed  in  smiths,  milkers,  painters,  makers  of  artificial 
flowers,  harp-players,  turners,  and  watchmakers.  The  case  of  a  watch- 
maker is  mentioned  by  Weir  Mitchell,^  whose  forefinger  and  thumb  were 

'  Onimus.  Gazette  Medicale,  Ahr,  1875:  Gaz.  hebd.  de  med.  et  de  chir.,  March, 
1877. 

^  Mitchell  (S.  Weir).  "On  functional  spasm."  The  American  Journal  of  the 
Medical  Sciences,  Vol.  II.,  1876. 


602  DISEASES   OF  THE   CERVICAL 

liable  to  be  affected  by  spasm  whenever  lie  attempted  to  seize  hold  of  a 
small  object,  such  as  a  screw,  and  great  force  had  to  be  used  before  the 
object  was  extricated. 

The  Course  of  all  these  diseases  is  almost  always  the  same.  They  begin 
very  gradually,  and  after  a  time  increase  more  rap)idly,  and  it  is  only  in 
rare  instances  that  they  are  observed  to  begin  almost  suddenly  after 
severe  over-exertion. 

The  duration  of  the  disease  is  generally  very  protracted,  and 
lasts  through  life  unless  its  progress  is  arrested  by  treatment. 

Morbid  Anatomy  and  Physiology. — Morbid  anatomy  has 
hitherto  not  thrown  any  light  upon  the  nature  of  this  disease,  and 
consequently  much  scope  is  afforded  for  speculation.  This  much 
is  certain,  that  the  more  specialised  the  action  the  more  likely 
are  the  muscles  engaged  in  producing  it  to  be  affected  by  feeble- 
ness or  spasm.  The  combinations  of  muscular  contractions 
concerned  in  writing  are  exceedingly  complex,  but  some  of  these 
combinations  are  more  special  than  others.  As  has  been  pointed 
out  by  Poore^  and  others,  the  operation  of  writing  is  divisible 
into  the  acts  of  (1)  prehension  of  the  pen,  (2)  moving  the  pen, 
and  (3)  poising  the  hand  and  forearm.  Of  these  acts  the  first 
and  the  third  are  the  most  special,  and  they  are  certainly  the 
most  liable  to  be  affected  in  writers'  cramp.  The  act  of  pre- 
hension is  mainly  effected  by  the  muscles  of  the  ball  of  the 
thumb  and  the  interossei,  and  either  spasm,  weakness,  or  inco- 
ordination of  the  movements  of  these  muscles  is  the  most  fre- 
quent symptom  of  the  disease.  Poising  of  the  hand  and  forearm 
is  effected  chiefly  by  the  pronators  and  supinators  of  the  forearm, 
and  as  the  hand  is  always  held  in  a  position  in  which  gravity 
aids  the  pronators,  the  most  delicate  part  in  preserving  the  atti- 
tude is  thrown  upon  the  supinators,  and  a  sudden  jerking  of  the 
latter  muscles  causing  the  hand  to  roll  outwards  is  not  an  unfre- 
quent  symptom  of  the  disease.  Duchenne^  divides  the  various 
forms  of  the  disease  into  two  varieties,  namely,  functional  impo- 
tence and  functional  spasm.  But  as  we  have  already  seen  (§  74), 
spasm  is  often  an  expression  of  diminished  voluntary  power,  or  of 
fatigue  of  the  neuro-muscular  apparatus  concerned  in  its  pro- 
duction.    Cramps  of  the  muscles  of  the  calf,  for  instance,  are 

1  Poore   (Gr.    V.).      "Writers'   Cramp;    its  pathology  and   treatment."     The 
Practitioner,  Vol.  X.,  1873,  p.  341;  and  Vol.  XI.,  1873,  pp.  1  and  85. 
^  Duchenne.     De  I'electrisation  localis^e.     Third  edit.,  Paris,  1872,  p.  1021. 


AND   BRACHIAL   PLEXUSES.  603 

most  liable  to  come  on  when  the  muscles  have  been  much 
fatigued  by  dancing,  and  cramps  of  other  muscles  are  apt  to 
supervene  when  the  muscles  are  strained  by  overwork.^  A 
gymnastic  performer,  who  called  himself  the  "American  con- 
tortionist," exhibited  his  feats  before  the  members  of  the 
Manchester  Medical  Society  last  winter.  This  man  could 
dislocate  most  of  the  joints  of  his  extremities  and  reduce  the 
dislocations  at  pleasure,  and  certainly  it  would  be  scarcely 
possible  to  imagine  a  man  with  a  more  finely  developed 
muscular  system.  While  showing  his  very  wonderful  exploits 
he  volunteered  the  statement :  "  I  gave  up  the  '  contortion 
business,'  because  of  late  years  I  have,  after  a  prolonged  per- 
formance, a  feeling  «of  cramp  in  the  muscles  of  my  back  which 
lasts  for  hours ;"  he  at  the  same  time  arched  his  body  backwards 
to  indicate  the  attitude  in  which  it  was  maintained  during  this 
time.  And  if  cramp  follows  so  closely  upon  over-action  of 
muscles  so  well  nourished  and  developed  as  those  of  this  man 
were,  how  much  more  likely  is  it  to  do  so  when  the  muscles 
are  ill  nourished,  owing  to  degenerated  vessels  or  from  some 
other  cause. 

So  far  then  as  theory  is  concerned  we  have  only  to  account  for 
one  form  of  writers'  cramp,  inasmuch  as  all  forms  are  caused  by 
an  undue  straining  of  the  muscular  groups  which  come  into  play 
during  the  act  of  writing.  The  disease,  therefore,  is  caused  by  a 
functional  or  molecular  lesion  of  some  part  of  the  nervous 
mechanism  which  regulates  the  movements  of  the  hand  in 
writing,  or  of  the  muscles  which  execute  these  movements.  The 
question  we  have  now  to  determine  is,  in  what  part  of  this  neuro- 
muscular apparatus  the  lesion  is  situated.  It  is  very  likely  that 
the  whole  of  this  apparatus  is  more  or  less  exhausted,  but  it  is 
possible  that  in  most  cases  there  is  a  particular  part  which  is 
more  affected  than  the  rest,  and  that  the  situation  of  this  part 
varies  in  different  cases.  It  is  very  probable  that  cramp  of  the 
calf  is  caused  by  irritation  of  the  intramuscular  nerve  endings,  or 
the  end  plates  in  the  muscular  fibres,  and  it  is  likely  that  some 
cases  of  writers'  cramp  are  caused  in  a  similar  manner.    Althaus^ 

1  See  Seeligmiiller.     "Zur  Pathogenese  der  peripheren  Krampfe."    St.  Petersb. 
med.  Wochenschr.,  No.  2,  1881  (Separatabdruck  aus). 
"Althaus  (J.).     Scriveners' palsy,  1870. 


604  DISEASES   OF   THE   CERVICAL 

believes  that  the  seat  of  the  lesion  is  the  mechanism  of  cells 
and  fibres  in  the  anterior  horns  of  the  cord  which  regulates 
the  movements  concerned  in  writing.  We  shall  hereafter  see 
that  these  cells  are  late  in  being  developed,  and  that  they  are 
also  small  and  lie  near  the  blood-vessels,  and  I  see  no  reason  to 
doubt  that  in  many  cases  of  this  disease  their  nutrition  is  mainly 
at  fault.  Solly^  believes  that  the  vesicular  structure  of  the 
spinal  cord  and  cerebellum,  which  harmonises  the  movements  of 
the  hand,  has  been  in  this  disease  overworked  and  disorganised, 
but  we  are  not  in  a  position  either  to  affirm  or  deny  the  suppo- 
sition. It  is  again  probable  that  the  lesion  is  sometimes  situated 
in  the  cortical  centre,  or  in  the  course  of  the  centrifugal  con- 
ducting paths  which  connect  it  with  the  spinal  cord.  We  know 
that  a  coarse  lesion  in  the  optic  thalamus  may  give  rise  to  hemi- 
ataxia,  and  some  cases  of  writers'  cramp  are  more  like  an  ataxic 
disturbance  than  to  either  paralysis  or  spasm.  The  psychical  dis- 
turbances which  form  such  a  prominent  feature  of  some  of  these 
cases  would  appear  to  indicate  that  the  affection  is  sometimes 
caused  by  a  lesion  of  the  cortical  centre.  All  forms  of  writers' 
cramp  must,  of  course,  be  carefully  distinguished  from  the  con- 
dition named  agraphia,  which  is  caused  by  a  destructive  lesion  of 
the  cortical  centre,  but  it  is  quite  possible  that  a  molecular  dis- 
integration of  the  cortical  cells,  in  which  the  irritability  of  some 
would  be  diminished  and  of  others  increased,  may  be  the  ana- 
tomical correlative  of  many  cases  comprised  under  the  general 
name  of  writers'  cramp.  We  should  say  that  the  main  lesion  is 
situated  either  in  the  ganglion  cells  of  the  spinal  cord,  or  in  the 
fibres  which  connect  these  with  the  muscles  in  all  those  cases  in 
which  the  electrical  reactions  of  the  muscles  are  diminished,  and 
that  it  is  situated  either  in  the  cortex  or  in  the  conducting  path 
above  the  spinal  level  in  all  those  cases  in  which  the  electrical 
reactions  are  increased. 

The  diagnosis  of  writers'  cramp  presents  no  special  difficulty. 
The  diseases  with  which  it  is  most  likely  to  be  confounded  are 
the  various  forms  of  tremor,  chorea,  paralysis  agitans,  progressive 
muscular  atrophy,  locomotor  ataxia,  arthritis  deformans,  hemi- 
plegia with  contracture,  and  disease  of  the  motor  nerves  of  the 
hand,   more   especially   of   the   ulnar   (Poore)  ;    but   a   careful 

1  Solly.     ''On  Scriveners'  palsy."    The  Lancet,  Vol.  I„  1867,  p.  561. 


AND   BRACHIAL   PLEXUSES.  605 

I 

examination  of  each  individual  case  should  prevent  anyone  from 
falling  into  the  error  of  mistaking  writers'  cramp  for  one  of 
these  affections.  In  order  to  determine  with  precision  the 
nature  of  the  disturbance  and  the  particular  muscles  which  are 
affected,  the  character  of  the  handwriting  must  be  studied,  and 
each  muscle  carefully  tested.  Search  should  also  be  made  for  a 
peripheral  source  of  irritation,  such  as  the  use  of  bad  writing 
materials,  or  a  painful  scar,  or  the  presence  of  neuritis. 

The  ijrognosis  has  hitherto  been  unfavourable,  but  the  treat- 
ment of  Wolff,  to  be  immediately  described,  gives  promise  of 
better  results  being  obtained  in  the  future.  In  some  cases  the 
disease  makes  steady  progress,  and  at  length  renders  writing 
impossible  in  spite  of  every  treatment.  Writers'  spasm  has  no 
direct  influence  on  the  general  health,  or  on  the  duration  of  life. 

Treatment. — Removal  of  the  cause  is  the  primary  require- 
ment. Writing,  pianoforte  playing,  or  whatever  else  may  have 
induced  the  disease,  must  either  be  entirely  discontinued  or 
limited  as  much  as  possible ;  in  recent  and  slight  cases  this 
alone  will  effect  a  cure  in  from  two  to  three  months  ;^  but  in 
severe  cases  there  is  little  chance  of  recovery  unless  the  patient 
can  give  up  his  occupation  for  six  months  or  a  year.  If  this 
cannot  be  done  the  patient  must  be  recommended  to  use  soft 
pens,  to  write  slowly  and  deliberately,  and  to  adopt  a  suitable 
penholder. 

Electricity  is  one  of  the  most  powerful  remedies  for  the  disease 
which  we  possess.  The  faradic  current  appears  to  have  little 
effect,  but  may  prove  useful  in  cases  where  there  is  local 
angesthesia  or  paralysis  of  particular  muscles.  The  spastic  forms 
are  made  worse  by  the  faradic  current. 

The  galvanic  current,  however,  frequently  gives  favourable 
results.  Different  piethods  of  applying  the  current  have  been 
advocated  by  various  electro-therapeutists,  but  the  best  known 
method  appears  to  be  to  galvanise  the  vertebral  column  in  the 
cervical  region  with  ascending  stabile  or  labile  currents,  and  to 
combine  with  this  the  peripheral  galvanisation  of  the  nerves  and 
muscles  of  the  arm  specially  affected.    Erb  recommends  also  the 

1  Solly  (Samuel).  "On  scriveners'  palsy,"  The  Lancet,  Vol.  L,  1867,  p.  561. 
See  also  Andrews  (H.  C. ).  "Notes  on  scriveners'  pal«y,  or  the  paralysis  of  writers," 
The  Lancet,  Vol.  II.,  1864,  p.  709.  And  Waller  (A.).  "  The  early  avoidance  of 
writers'  cramp,"  The  Practitioner,  Vol.  XXV.,  1S80,  p.  101. 


606  DISEASES   OF  THE  CERVICAL 

transmission  of  galvanic  currents,  both  transversely  and  in  an 
antero-posterior  direction  through  the  head.  The  galvanic  treat- 
ment should  be  continued  for  several  months  at  the  least,  and  the 
application  may  be  made  as  often  as  from  three  to  six  times  in 
the  week,  but  the  current  employed  must  not  be  too  strong. 

The  most  successful  treatment  of  writers'  cramp  known  up  to 
the  present  is  the  one  practised  by  WolfF,^  which  is  a  combination 
of  gymnastics  and  massage.  The  gymnastic  exercises  consist  of 
both  active  and  passive  movements.  In  the  active  form  of 
exercise  the  patient  is  instructed  to  execute,  three  or  four  times 
a  day,  a  series  of  vigorous  movements  with  the  affected  extre- 
mity, the  hand  being  opened  and  closed  in  quick  succession. 
The  number  of  these  movements,  and  consequently  the  duration 
of  each  exercise,  is  progressively  increased  until  a  duration  of 
about  half  an  hour  is  attained  for  each  sitting.  In  the  passive 
movements  the  operator  produces  forcible  traction  three  or  four 
times  in  a  day  upon  each  of  the  affected  muscles  separately  in 
the  direction  of  its  length.  This  appears  to  be  the  most  delicate 
part  of  the  treatment,  inasmuch  as  if  too  little  strength  is  em- 
ployed the  cure  is  delayed,  and  if  too  much  the  disorder  is 
aggravated.  When  the  spasm  is  notably  diminished,  which 
usually  occurs  in  a  short  time,  the  patient  is  encouraged  to  take 
slow  and  graduated  exercises  in  writing.  The  operator  practises 
daily  massage  of  the  affected  extremity,  particular  stress  being 
laid  upon  percussion  over  the  affected  muscles  with  the  ulnar 
border  of  the  hand.  Two  of  Charcot's  patients,  suffering  from 
writers'  cramp,  were  submitted  to  Wolff  for  treatment,  and  were 
cured  by  him  in  fifteen  days.  When  no  amelioration  of  the 
symptoms  is  produced  in  four  or  five  sittings,  Wolff  believes  that 
the  treatment  may  be  abandoned  as  not  likely  to  prove  useful. 

Mechanical  means  have  been  resorted  to  in  severe  cases.^  The 
simplest  method  of  this  kind  is  to  insert  the  pen  into  a  cork  or 
thick  piece  of  wood,  or  to  fasten  it  by  means  of  a  ring  to  the 
first  or  middle  finger.  The  attempts  which  have  been  made  to 
counteract  particular  spasmodic  movements  by  means  of  com- 

'  See  Vigouroux  (R.).  "Du  traitement  de  la  crampe  des  ecrivains  par  la 
methode  de  WolfiE  (de  Francfort-sur-le-Main)."  Le  Progrea  Medical,  Tome  X., 
1882,  p.  37. 

^  F.rh  (W.).  The  diseases  of  the  peripheral  nerves.  Ziemssen's  Cyclopaedia, 
Vol.  XL,  1876,  p.  358. 


AND   BRACHIAL   PLEXUSES.  607 

plicated  apparatus  have  all  proved  unsuccessful.  Many  patients 
are  relieved  by  applying  a  narrow  bandage  or  a  strip  of  court 
plaster  firmly  round  the  wrist. 

Tenotomy  of  the  affected  muscles  has  been  performed  by 
Stromeyer,  Dieffenbach,  Langenback,  and  others,  but  the  results 
obtained  have  not  been  very  encouraging.  The  treatment  of 
the  other  professional  spasms  must  be  conducted  on  essentially 
similar  principles. 

(2)  Paralysis  or  the  Muscles  supplied  by  the  Brachial  Plexus. 

§  291.  The  paralytic  affections  of  the  brachial  plexus  maybe 
divided  into  (a)  paralyses  of  the  muscles  of  the  neck  and  trunk, 
and  (6)  of  those  of  the  upper  extremity. 

(a)  Paralysis  of  Special  Muscles  and  Groups  of  Muscles  of 
the  Neck  and  Trunk. 

(1)  Paralysis  of  the  Pectoralis  Major  and  Pectoralis  Minor. 
These  muscles  are  supplied  by  the  anterior  thoracic  nerves,  and 
separate  paralysis  of  them  is  rare.  There  is  impairment  or  loss 
of  the  power  of  adducting  the  arm  to  the  thorax,  and  the  patient 
is  unable  to  seize  the  opposite  shoulder  with  the  hand,  or  to 
resist  passive  abduction  of  the  arm.  If  the  muscles  are  also 
atrophied,  the  sub-clavicular  fossa  is  considerably  deepened,  the 
ribs  and  intercostal  spaces  are  strongly  marked,  and  the  anterior 
wall  of  the  axilla  is  reduced  to  a  flaccid  fold  of  skin. 

(2)  Paralysis  of  the  Rhomboidei  and  Levator  Anguli  Scapulce. 
These  muscles  are  supplied  by  the  fifth  cervical,  but  the  levator 
usually  receives  a  branch  from  the  third  cervical  nerve  also. 
Paralysis  of  them  renders  forced  elevation  of  the  scapula  without 
rotation  impossible.  The  diagnosis  is  difficult,  except  when 
there  is  coincident  paralysis  and  atrophy  of  the  trapezius,  and 
in  that  case  the  patient  is  unable  to  draw  the  scapula  towards 
the  vertebral  column,  while  paralysis  of  the  levator  anguli 
scapulae  is  recognised  by  the  inability  to  effect  the  characteristic 
elevation  of  the  scapula. 

(3)  Paralysis  of  the  Latissimus  Dorsi. — This  muscle  is 
supplied  by  the  long  subscapular  nerve,  and  paralysis  of  it  is 
rare  as  an  isolated  affection,  although  common  as  a  subordinate 


608 


DISEASES   OF  THE  CERVICAL 


symptom  of  progressive  muscular  atrophy.  The  arm  cannot  be 
adducted  with  the  usual  amount  of  force,  and  difficulty  is  ex- 
perienced in  moving  the  hand  to  the  buttock. 


Fig.  92. 


Fig.  92  (from  Heath's  '  'Anatomy  ").    First,  second,  and  part  of  the  third  laye^'  of 
Muscles  of  the  Back.— The  first  layer  occupies  the  right ;  the  second  the  left  side. 


1,  Trapezius. 

2,  Ligamentum  nucha. 

3,  Acromion  process  and  spine  of  the 

scapula. 

4,  Latissimus  dorsi. 
.5,  Deltoid. 

6,  Muscles  of  the  dorsum  of  the  right 

scapula:  infraspinatus,  teres  minor, 
and  teres  major. 

7,  Obliquus  externus. 

8,  Gluteus  medius. 

9,  Glutei  maximi. 

10,  Levator  anguli  scapulse. 

11,  Rhomboideus  minor. 

12,  Rhomboideus  major. 

13,  Splenius  capitis ;  the  muscle  internal 


to,  and  overlaid  by,  the  splenius,  is 
the  complexus. 

14,  Splenius   colli,   partially   seen ;    the 

common  origin  of  the  splenius  is 
seen  attached  to  the  spinous  pro- 
cesses below  the  origin  of  rhom- 
boideus major. 

15,  Vertebral  aponeurosis. 

16,  Serratus  posticus  inferior. 

17,  Supraspinatus. 

18,  Infraspinatus. 

19,  Teres  minor. 

20,  Teres  major. 

21,  Long  head  of  triceps. 

22,  Serratus  magnus. 

23,  Obliquus  internus. 


AND  BRACHIAL   PLEXUSES. 


609 


(4)  Paralysis  of  the  Outward  and  Inward  Rotators  of  the 
Upper  Arm. — The  outward  rotators  of  the  arm  consist  of  the 
infraspinatus  muscle,  supplied  by  the  suprascapular,  and  the 


Fig.  93.  Muscles  of  the  Anterior  Aspect  of  the  Tr 
of  the  body  the  superficial  layer  is  seen, 

1,  Pectoralis  major. 

2,  Deltoid. 

3,  Anterior  border  of   the    latiesimus 

dorsi. 

4,  Serratus  magnus. 

5,  Subclavius,  right  side. 

6,  Pectoralis  minor. 

7,  Coraco-brachialis. 

8,  Upper  part  of  the  biceps,  showing 

its  two  heads. 

9,  Ooracoid  process  of  the  scapula. 

10,  Serratus  magnus,  right  side. 

11,  External  intercostal  muscle  of  the 

fifth  intercostal  space. 

12,  External  oblique. 

13,  Its  aponeurosis :  the  median  line  to 

the  right  of  this  number  is  the 
linea  alba;  the  curved  line  to  its 


14, 
1.5, 
16, 


17, 
18, 
19, 

20, 


unk  (from  Wilson). — On  the  left  side 
on  the  right  the  deeper  layer. 

left,  the  linea  semilunaris ;  the 
transverse  lines  above  and  below 
the  number,  the  lineae  transversa. 

Poupart's  ligament. 

External  abdominal  ring. 

Eectus  muscle  of  the  right  side 
brought  into  view  by  the  removal 
of  the  anterior  segment  of  its 
sheath ;  *  posterior  segment  of  its 
sheath  with  the  divided  edge  of 
the  anterior  segment. 

Pyramidalis  muscle. 

Internal  oblique. 

Conjoined  tendon  of  the  internal 
oblique  and  trans versalis. 

The  lower  curved  border  of  the  in- 
ternal oblique  miiacle. 


VOL.  I. 


NN 


610  DISEASES   OF  THE   CERVICAL 

i 

teres  minor,  supplied  by  the  circumflex  nerves;  wlieii  these 
muscles  are  paralysed  all  the  movements  requiring  outward 
rotation  of  the  arm  are  rendered  difficult  or  impossible.  la 
writing  and  drawing,  the  formation  of  straight  lines  from  left  to 
right  is  in  part  dependent  upon  the  contraction  of  the  infra- 
spinatus and  teres  muscles,  so  that  these  manual  operations  are 
rendered  somewhat  difficult.  If  the  arm  be  rotated  inwards,  the 
patient  is  unable  to  rotate  it  outwards.  When  the  muscles  are 
atrophied,  there  is  an  increased  depression  of  the  infraspinatus 
fossa. 

The  inward  rotators  consist  of  the  subscapularis,  the  teres 
major,  and  in  part  also  the  latissimus  dorsi,  which  are  all  in- 
nervated by  the  subscapular  nerves.  When  these  are  paralysed, 
all  movements  of  the  hand  towards  the  opposite  side  of  the 
body  or  head  are  rendered  difficult  or  impossible,  and  when 
the  arm  is  rotated  outwards  the  patient  no  longer  retains  the 
power  to  rotate  it  inwards,  except  perhaps  to  a  limited  degree  by 
means  of  the  pectoralis  major.  The  arm  is  maintained  in  a 
position  of  abnormal  rotation  outwards  ;  but  contrary  to  what 
occurs  when  the  outward  rotators  are  contracted,  passive 
mobility  is  preserved. 

(5)  Paralysis  of  the  serratus  magnus  muscle,  which  is  inner- 
vated by  the  posterior  or  long  thoracic  nerve,  sometimes  occurs 
as  an  isolated  affection.  The  long  course  and  comparatively 
superficial  position  of  the  nerve  exposes  it  to  direct  injury, 
from  pressure,  contusion,  blows,  concussion  of  the  shoulder 
through  a  heavy  backward  fall  on  the  ice,^  or  gunshot  wounds. 
Both  unilateral  and  bilateral  paralysis  of  the  serratus  have  been 
observed  after  over-exertion  of  the  muscles  of  the  shoulder,  as, 
for  example,  in  mowers,  puddlers,  and  other  mechanics.  In  these 
cases  it  is  probable  that  the  nerve,  as  it  perforates  the  scalenus 
medius,  suffers  injury  when  violent  and  repeated  movements  of 
the  shoulder  are  performed.^  Paralysis  of  this  muscle  is  also 
caused  by  exposure  to  cold  ;  it  is  more  frequent  in  men  than  in 
women,  and  may  supervene  as  a  sequel  of  typhoid  fever.     It 

»Nenschler  (F.).  "Ein  Fall  von  Serratuslahmunj  "  Aroh.  der  Heilkunde, 
Bd.  III.,  1862,  p.  78. 

*Erb(W.).  "On  the  diseases  of  the  peripheral  nerves."'  Ziemasen's  Cvclo- 
psedia,  Vol.  XL,  1876,  p.  530. 


AND   BRACHIAL   PLEXUSES.  611 

may  also  occur  as  a  symptom  of  spiual  or  cerebral  disease,  but 
in  that  case  other  muscles  are  coincidently  affected,  especially 
the  lower  portion  of  the  trapezius,  the  latissimus  dorsi,  the 
rhomboidei,  &c. 

Sytnptoms. — The  paralytic  symptoms  are  frequently  preceded 
for  some  time  by  neuralgic  pains  in  the  neck  and  round  the 
shoulder-blade,  and  some  difficulty  may  be  experienced  in  per- 
forming certain  movements.  When  the  paralysis  is  once  estab- 
lished, the  scapula,  whilst  the  arm  is  hanging  by  the  side,  is 
somewhat  raised  and  approximated  to  the  vertebral  column ;  it 
is  so  rotated  on  its  axis  that  its  inner  border  is  directed  obliquely 
upwards  and  outwards,  and  its  inferior  angle,  which  stands  out 
slightly  from  the  thoracic  wall,  is  drawn  close  to  the  vertebral 
column.  These  symptoms  are  caused  by  the  unantagonised 
action  of  the  rhomboidei,  levator  anguli  scapula,  trapezius,  and 
pectoralis  minor. 

When  certain  movements  are  performed,  very  striking  symp- 
toms make  their  appearance  on  the  side  affected.  The  patient 
experiences  some  difficulty  in  raising  the  extended  arm  above 
the  horizontal  level.  The  reason  of  this  is  that  the  rotation  for- 
wards of  the  inferior  angle  of  the  scapula  with  the  consequent 
elevation  of  its  external  angle,  which  is  mainly  effected  by  the 
serratus,  is  much  impaired,  but  as  the  rotatory  action  of  the 
trapezius  can  still  be  brought  into  play,  the  arm  can  be  raised  to 
a  level  midway  between  the  horizontal  and  vertical  positions  ; 
during  this  action  the  patient  instinctively  inclines  his  body  to 
the  opposite  side.^  If  the  observer  rotates  the  scapula  forwards 
and  fixes  the  bone  in  that  position,  the  patient  is  enabled  to 
raise  the  arm  to  a  vertical  position.  When  the  arm  is  raised  to 
the  horizontal  position,  the  inner  border  of  the  scapula  is  drawn 
more  and  more  inwards  towards  the  vertebral  column,  pushing  a 
mass  of  muscle  before  it ;  and  if  the  paralysis  be  bilateral,  the 
inner  borders  of  the  scapulee  may  actually  touch  one  another. 
If  the  raised  arm  be  brought  forward,  the  inner  border  of  the 
scapula  becomes  more  and  more  separated  from  the  costal  wall, 
thus  forming  a  deep  fossa  in  which  the  hand  may  easily  be  laid 
and  the  inner  surface  of  the  bone  felt.  In  bilateral  paralysis 
the  scapulse  enclose  a  deep  hollow  in  which  the  muscular  bellies 

^  Duchenne.    De  I'electrisation  localisde.    Third  edit.,  Paris,  1872,  p.  940. 


612  DISEASES   OF   THE   CERVICAL 

of  the  rhomboidei  project.  If  contraction  of  the  muscle  can  be 
effected  by  faradic  irritation  of  its  nerves,  the  characteristic 
deformity  is  at  once  removed.  Other  movements  are  also  inter- 
fered with.  It  is  difficult  to  cross  the  arms  in  front  of  the 
chest,  and  to  move  the  apex  of  the  shoulder  forwards  as  is 
required  in  delivering  a  blow  in  fencing,  and  the  patient  offers 
less  resistance  on  the  paralysed  side  to  forcible  retraction  of  the 
shoulder.  The  chest  does  not  expand  so  much,^  and  the  digita- 
tions  of  the  serratus  magnus  with  the  external  oblique  are  not 
so  marked  on  the  paralysed  as  on  the  healthy  side  during  forced 
inspiration. 

Disturbances  of  sensibility  are  only  rarely  present ;  consider- 
able atrophy  of  the  affected  muscle  is  usually  observed  in  pro- 
gressive muscular  atrophy,  as  well  as  in  severe  traumatic  neuritis, 
but  it  only  occurs  to  a  slight  degree  in  paralyses  of  central  origin, 
and  in  mild  rheumatic  cases. 

In  traumatic  and  severe  rheumatic  paralyses  the  reaction  of 
degeneration  is  present ;  in  paralysis  from  progressive  muscular 
atrophy  there  is  simple  diminution  of  the  electrical  excitability ; 
and  in  central  paralyses,  and  those  produced  by  slight  pressure, 
the  excitability  undergoes  no  change,  or  only  a  slight  diminu- 
tion. The  course  of  paralysis  of  the  serratus  varies.  Rheumatic 
paralyses  and  those  arising  from  slight  pressure  almost  always 
recover.  Traumatic  paralyses  are  usually  of  long  duration,  and 
are  not  unfrequently  incurable.  The  paralyses  arising  from 
progressive  muscular  atrophy  are  also  incurable.  In  protracted 
cases  gradual  contraction  of  the  antagonist  muscles  takes  place. 

The  following  case  of  paralysis  of  the  serratus  magnus  was 
kindly  sent  to  me  by  Mr.  Hardie,  and  I  am  indebted  for  the 
notes  of  the  case  to  Mr.  Challinor,  who  was  at  the  time  one  of 
the  house  physicians  at  the  Royal  Infirmary.  The  accompany- 
ing engraving  is  from  a  sketch  of  the  patient  by  Mr.  Withers. 

G.  B.,  £et.  thirty-two  years,  boiler-maker,  entered  the  Royal  Infirmary 
on  December  24th,  1879.  Five  or  six  weeks  before  his  admission,  he  was 
walking  on  a  frosty  morning  on  an  inclined  plank  of  wood,  when  his  feet 
slipped,  and  he  fell  backwards  and  to  the  left.  He  threw  out  his  right 
arm  horizontally  to  protect  himself,  and  the  edge  of  the  plank  struck  him 

'  Poore  (G.  V.).  "  Case  of  paralysis  of  the  serratus  magnus."  Clinical  Society's 
Transactions,  Vol.  VIII.,  1875,  p.  83. 


AND   BRACHIAL   PLEXUSES. 


613 


beloTS'  the  riglit  armpit  and  shoulder  blade.  He  felt  little  or  no  pain  at  the 
time,  and  the  skin  over  the  part  struck  did  not  subsequently  become  dis- 
coloured. Some  days  after  the  accident  he  felt  that  he  could  not  raise 
his  right  arm  as  well  as  usual,  but  he  did  not  think  there  was  anything 
seriously  -wrong  until  a  fortnight  ago,  when  a  companion  drew  his  attention 
to  a  deformity  of  his  right  shoulder  blade. 

Present  Condition. — As  the  patient  stands  with  his  arms  hanging  by 
his  side,  the  only  noticeable  deformity  is  that  the  inferior  angle  of  the  right 

Fig.  94. 


scapula  projects  somewhat  fm^ther  from  the  costal  wall,  is  somewhat  nearer 
the  middle  line,  and  on  a  slightly  higher  level  than  the  corresponding- 
angle  of  the  left  scapula.  The  right  scapula  is  also  rotated,  so  that  its 
internal  border  slants  slightly  upwards  and  outwards,  its  inferior  border 
being  more  horizontal  than  that  of  the  left.  The  superior  internal  angle 
of  the  right  scapula  is  on  a  slightly  higher  level  than  that  of  the  left,  but 
the  external  angle  with  the  shoulder  of  the  right  side  appears  to  be  on  the 
same  level  as  that  of  the  left. 

When  the  patient  extends  his  arms  horizontally  outwards  the  right 
shoulder  blade  is  drawn  backwards  and  inwards,  so  that  its  internal  border 
is  parallel  with  and  close  to  the  spines  of  the  dorsal  vertebrae  {Fig.  94). 


614  DISEASES   OF  THE   CERVICAL 

The  internal  border  of  the  left  scapula,  on  the  other  hand,  slants  obliquely 
from  above  downwards  and  from  within  outwards,  the  upper  angle  being 
close  to  the  spines  of  th-e  vertebrse,  and  the  lower  one  4^in.  removed  from 
them.  The  right  scapula  is  one  inch  higher  than  the  left,  and  the  internal 
border  of  the  former  stands  out  two  inches  from  the  costal  wall,  while  the 
internal  border  of  the  left  is  closely  applied  to  it. 

On  the  arms  being  extended  horizontally  forwards  the  right  scapula  is 
drawn  outwards  and  rotated  on  its  vertical  axis,  so  that  it  projects  from ' 
the  chest  like  a  wing,  the  internal  border  being  2|in.  from  the  costal  wall, 
whilst  the  corresponding  border  of  the  left  is  closely  applied  to  it.  The 
lower  angle  of  the  right  scapula  is  Ijin.  from  the  middle  line  ;  that  of  the 
left  6jin.  The  uj)per  and  internal  angle  of  the  right  is  |in.,  and  that  of 
the  left  2in.  from  the  spines  of  the  vertebra) ;  while  the  right  scapula 
stands  also  l^in.  higher  than  the  left. 

On  the  arms  being  crossed  in  front,  so  that  the  tips  of  the  fingers 
touch  opposite  shoulders,  the  deformity  of  the  right  shoulder  blade  almost 
disappears,  the  inner  border  being  closely  appHed  to  the  costal  wall.  The 
lower  angle  of  the  right  is  4|in.,  and  of  the  left  Sjin.  from  the  middle  line ; 
and  the  internal  superior  angle  of  the  right  3in.,  and  of  the  left  3jin.  from 
the  middle  hne.  The  upper  border  of  the  right  is  one  inch  higher  than 
that  of  the  left. 

When  the  patient  raises  the  arms  in  a  vertical  direction  the  left  becomes 
closely  applied  to  the  left  ear,  while  the  right  is  Tin.  removed  from  the  right 
ear.  The  inferior  angle  of  the  right  scapula  is  now  2jin.,  and  of  the  left 
7-|in.  from  the  spines  of  the  vertebrse;  the  inner  border  of  the  right  scapula 
is  2|in.  from  the  costal  wall,  and  that  of  the  left  is  closely  applied  to  it, 
but  the  inferior  angles  of  both  scapulae  are  on  the  same  level. 

"When  the  patient  takes  a  deep  inspiration,  the  digitations  of  the 
serratus  magnus  with  the  external  oblique  are  plainly  visible  in  the  left 
side,  but  the  wall  of  the  chest  remains  quite  smooth  on  the  right  side. 
During  quiet  respiration  each  half  of  the  chest  measures  18^in. ;  on  deep 
expiration  the  measurements  are  18in. ;  but  on  deep  inspiration  the  left 
side  measures  19|in.,  and  the  left  18^in.  only. 

When  a  faradic  current  is  passed  through  the  anterior  fibres  of  the 
deltoid  of  the  injured  side,  a  deformity  of  the  shoulder  blade  is  produced 
similar  to  that  caused  when  the  arms  are  extended  laterally  at  right  angles 
to  the  body.  When  the  current  is  passed  through  the  anterior  fibres  of 
the  left  deltoid,  the  shoulder  blade  of  that  .side  assumes  a  position  closely 
resembling  that  of  the  diseased  side  when  the  arms  are  hanging  by  the 
side.  The  rhomboidei  muscles  act  energetically  to  a  weak  faradic  current. 
No  contraction  of  the  right  serratus  magnus  can  be  obtained  by  either 
current  when  applied  cutaneously,  but  distinct  contractions  are  obtained 
to  a  galvanic  current  from  twenty  cells  Leclanche  by  means  of  electric 
acupuncture.  He  was  ordered  five  grains  of  iodide  of  potassium  to  be 
taken  three  times  a  day,  and  the  galvanic  current  to  be  passed  through 
the  paralysed  muscle  by  means  of  electric  acupuncture. 


AND   BRACHIAL   PLEXUSES. 


615 


The  patient  remained  a  fortnight  in  the  infirmary  without  presenting 
any  notable  signs  of  improvement,  and  then  became  an  out-patient. 
Towards  the  end  of  January,  the  affected  muscle  began  to  contract 
decidedly  during  voluntary  movements  of  the  arm,  but  there  was  no 
manifest  change  in  the  electric  reactions  obtained.  From  this  date  rapid 
improvement  took  place,  but  I  lost  sight  of  him  for  a  time,  and  did  not  see 
him  until  the  month  of  May  following,  when  he  presented  himself  at  my 
rooms,  and  I  could  not  detect  a  trace  of  deformity,  but  the  right  serratus 
magnus  did  not  even  then  respond  so  readily  to  the  faradic  current  as  the 
corresponding  muscle  of  the  left  side. 

Reinarks. — The  j)aralysis  in  this  case  was  not  likely  to  have  been  caused 
by  direct  injury  to  the  muscle,  inasmuch  as  the  blow  received  under  the 
armpit  during  the  fall  appears  to  have  been  of  a  very  trifling  character.  It 
is  more  probable  that  there  was  injury  and  consequent  neuritis  of  the  long 
thoracic  nerve  as  it  passes  through  the  scalenus  medius,  caused  by  the 
sudden  contraction  of  the  muscle  when  the  patient  threw  out  his  right 
arm  in  order  to  protect  himself  while  falling.  The  deformities  produced 
by  passing  a  faradic  current  through  the  anterior  fibres  of  the  deltoid  on 
the  paralysed  and  sound  sides   show  that  contraction  of  these  fibres 

Fig. -95. 


Kectus  Abdominis  J 
(Intercostal  Nerves)" 


^    SeiTatus  Magnus 
Latissimus  Dorsi 


,  Obliquus  Externus 
f  (Intercostal  Nerves) 


Transversalis 


■iFiG.  95.    Surface  of  Trunk 


618  DISEASES   OF   THE   CERVICAL 

contribxites  greatly  in  producing  the  deformities  of  the  shoulder  blade 
on  the  affected  side  when  the  arm  is  horizontal.  It  is  also  probable 
that  contraction  of  the  pectoralis  minor  contributes  in  both  instances  in 
producing  the  deformity. 

The  diagnosis  of  paralysis  of  the  serratus  when  uncomplicated 
presents  no  difficulty ;  it  may  be  recognised  by  reference  to  the 
description  of  the  symptoms.  The  prognosis  is  determined  by 
the  cause  of  the  disease,  the  degree  of  the  atrophy,  the  altera- 
tions of  the  electrical  excitability  and  the  time  that  the  disease 
has  lasted. 

Treatment. — The  treatment  of  these  various  forms  of  para- 
lysis must  be  conducted  on  general  principles,  and  consists  of 
graduated  exercises,  shampooing,  and  friction.  The  use  of  the 
galvanic  and  faradic  currents,  however,  affords  the  best  results, 
and  in  the  severer  forms  electric  acupuncture  is  a  valuable 
method  of  treatment.  The  annexed  diagram  {Fig.  95)  shows 
the  motor  points  of  the  surface  of  the  trunk. 

(6)  Paralysis  of  the  Muscles  of  the  Upper  Extremity. 

(1)  Paralysis  of  the  Muscles  supplied  by  the  Circumflex 
Nerve. — The  circumflex  nerve  may  be  paralysed  by  various 
injuries  aifecting  the  shoulder  and  shoulder-joint,  or  the  deltoid 
muscle  itself.  Rheumatism  and  chronic  inflammation  of  the 
shoulder -joint  often  cause  paralysis  of  the  deltoid,  and  it  is 
not  unfrequently  produced  by  exposure  to  cold  and  neuritis. 
Paralysis  of  the  circumflex  is  also  a  symptom  of  disease  of  the 
brachial  plexus,  of  central  paralyses  of  all  kinds,  of  saturnine 
paralysis,  of  progressive  muscular  atrophy,  and  of  pseudo- 
muscular  hypertrophy.  The  symptoms  are  almost  exclusively 
those  of  paralysis  of  the  deltoid  muscle.  The  arm  cannot  be 
raised,  and  when  attempts  are  made  to  raise  it,  the  deltoid 
remains  quite  relaxed  and  the  arm  lies  flat  and  immovable 
against  the  wall  of  the  thorax.  It  is  also  impossible  to  raise 
the  arm  in  a  forward  direction. 

The  muscle  frequently  atrophies  and  the  shoulder-joint  be- 
comes so  loose  that  a  deep  groove  can  be  felt,  through  the 
atrophied  muscle,  between  the  head  of  the  humerus  and  the 
articular  surface  of  the  scapula.     There  juay  be  pain  in  the 


AND   BRACHIAL   PLEXUSES. 


617 


Fig.  96. 


shoulder-joint  and  in  the  substance  of  the  muscle,  but  other 
sensory  disturbances  in  the  region  of  distribution  of  the  circum- 
flex nerve  are  rare. 

The  electric  excitability  may  be  normal  at  first,  and  then 
gradually  undergo  diminution,  especially  in  progressive  muscular 
atrophy,  and  in  paralysis  resulting  from  rheumatism  of  the 
shoulder-joint.  The  various  phases  of  the  reaction  of  degenera- 
tion maybe  present  in  the  whole  muscle,  or  limited  to  particular 
portions  of  it. 

When  the  paralysis  is  persistent  the  atrophy  gradually  in- 
creases, the  joint  becomes  loose,  and  in  many  cases  anchylosis 
eventually  takes  place,  the  arm  re- 
maining more  or  less  useless. 

(2)  Paralysis  in  the  Region  of 
Distribution  of  the  Musculo- Cuta- 
neous Xerve. — Paralysis  of  this  nerve 
leads  to  impairment  or  complete 
impossibility  of  flexing  the  forearm 
on  the  upper  arm,  more  especially 
when  an  attempt  is  made  to  bend 
the  arm  in  a  position  of  supination, 
inasmuch  as  in  that  position  the 
flexor  action  of  the  supinator  longus 
is  no  longer  exerted.  The  seat  of 
the  lesion  may  often  be  ascertained 
by  the  presence  of  anaesthesia  along 
the  radial  border  of  the  forearm. 
This  form  of  paralysis  is  usually  asso- 
ciated with  paralysis  of  other  muscles 
innervated  by  branches  from  the 
brachial  plexus,  and  is  rare  as  an 
isolated  affection. 

(3)  Paralysis  in  the  Region  of 
Distribution  of  the  Muscvio- Spiral 
Nerve. — The  musculo-spiral  nerve  is 
more  frequently  affected  than  any- 
other  branch  of  the  brachial  plexus, 
probably  owing  to  its  exposed  posi- 
tion as  it  winds  round  the  upper  arm. 


Fig.  96.  Muscles  of  the  Anterior 
Aspect  of  the  Uppefr  Arm  (from 
Wilson). 

1,  Coracoid     process     of     the 

scapula. 

2,  Coraco  -  clavicular    ligament 

(trapezoid). 

3,  Coraco-acromial  ligament. 

4,  Subscapularis. 

5,  Teres  major. 

6,  Coraco-brachialis. 

7,  Biceps. 

8,  Upper  end  of  the  radius. 

9,  Brachialis  anticus. 

10,  Internal  head  of  the  triceps. 


618 


DISEASES   OF  THE   CERVICAL 

Fig.  98. 


Fig.  97.   Superficial  Muscles  of  the  back 
of  Forearm  (from  Wilson). 

1,  Biceps. 

2,  Brachialis  anticus. 

3,  Lower  part  of  the  triceps,  inserted 

into  the  olecranon, 

4,  Supinator  longus. 

5,  Extensor  carpi  radialis  lougior. 

6,  Extensor  carpi  radialis  brevior. 

7,  Tendons  of  insertion  of  these  two 

muscles. 

8,  Extensor  communis  digitorum. 

9,  Extensor  minimi  digiti. 

10,  Extensor  carpi  ulnaris. 

11,  Anconeus. 

12,  Flexor  carpi  ulnaris. 

13,  Extensor   ossis    metacarpi   and   ex- 

tensor primi  internodii  pollicis 
lying  together. 

14,  Extensor  secundi  internodii  pollicis. 

15,  Posterior   annular    ligament.      The 

tendons  of  the  common  extensor 
are  seen  on  the  back  of  the  hand, 
and  their  mode  of  insertion  on  the 
dorsum  of  the  fingers. 


Fig.  98.    Deep  Muscles  of  the  back   of 
Forearm  (from  Wilson). 

1,  Humerus. 

2,  Olecranon, 

3,  Ulna. 

4,  Anconeus. 

5,  Supinator  brevis. 

6,  Extensor  ossis  metacarpi  pollicis, 

7,  Extensor  primi  internodii  pollicis. 

8,  Extensor  secundi  internodii  pollicis. 

9,  Extensor  indicis, 

10,  First  dorsal  interosseous  muscle. 
The  other  three  dorsal  interossei 
are  seen  between  the  metacarpal 
bones  of  their  respective  fingers. 


AND  BRACHIAL  PLEXUSES.  619 

Paralysis  of  this  nerve  is  supposed  to  be  frequentl}''  caused  by 
exposure  to  a  draught  of  cold  air,  or  sleeping  on  damp  earth,  but 
it  is  more  probable  that  in  the  majority  of  these  cases  there  is 
compression  of  the  nerve.  This  occurs  very  commonly  during 
deep  and  prolonged  sleep,  especially  in  states  of  intoxication, 
and  under  these  circumstances  the  paralysis  appears  when  the 
patient  awakes.  The  nerve  may  also  be  subjected  to  compression 
by  improperly  constructed  crutches,^  and  in  various  other  ways 
which  need  not  be  detailed.  Rheumatic  paralysis  of  the  musculo- 
spiral  is  by  no  means  so  frequent  as  was  at  one  time  believed. 
Paralysis  of  the  nerve  may  be  caused  by  various  wounds  and 
contusions  of  the  arm,  and  by  fractures  of  the  humerus^  and 
dislocations  of  the  shoulder.  Hysterical  paralyses  of  the  mus- 
culo-spiral  are  rare.  This  nerve  is  frequently  implicated  in 
central  and  especially  in  cerebral  paralysis.  Lead  poisoning  is 
a  frequent  cause  of  paralysis  of  the  musculo-spiral  nerve,  the 
affection  being  usually  preceded  by  colic  and  arthralgia.  Lead 
paralysis  usually  commences  in  the  muscles  supplied  by  the 
musculo-spiral  in  the  forearm,  and  especially  the  extensor  com- 
munis digitorum,  but  ultimately  the  muscles  of  the  hand,  upper 
arm,  and  shoulder,  as  well  as  those  of  the  lower  extremities,  are 
not  unfrequently  affected. 

Symptoms. — When  the  musculo-spiral  nerve  is  completely 
paralysed,  the  hand  is  kept  in  a  state  of  flexion,  it  hangs  flaccid 
and  cannot  be  raised  or  extended ;  the  thumb  is  flexed  and 
adducted,  and  the  fingers  are  flexed  over  the  thumb.  When  an 
attempt  is  made  to  extend  the  fingers,  the  interossei  and  lum- 
bricales  alone  act,  and  these  only  extend  the  two  terminal 
phalanges,  whilst  they  flex  the  basal  phalanx.  The  thumb  and 
index  finger  cannot  be  abducted  or  extended.  There  is  inability 
to  supinate  the  forearm,  especially  when  it  is  extended  so  as  to 
exclude  the  action  of  the  biceps;  it  cannot  be  bent  and  half 
supinated  by  the  supinator  longus.  Paralysis  of  the  supinator 
longus  is  readily  recognised  by  requesting  the  patient  to  make 
a  powerful  effort  to  flex  the  arm  against  a  resisting  object  when 
the  arm  is  maintained   in  a  half-flexed  position,  and  midway 

'  Krafft-Ebing.  "Kriickenlahmung."  Deutsches  Arch.  f.  klin.  med.,  Bd.  IX., 
1872,  p.  125. 

'^  Busch.  "  Heilung  einer  Radialslahmung  nach  Oberarinbruch."  Berl.  klin. 
Wochenschr.,  1872,  No.  34. 


620  DISEASES   OF   THE   CEllVICAL 

between  pronation  and  supination ;  the  muscle  does  not  then 
enter  into  contraction,  but  remains  flaccid  and  soft.  If  the 
triceps  be  simultaneously  affected,  the  patient  cannot  extend  the 
arm  with  any  degree  of  force.  If  the  hand  be  laid  upon  a  table, 
no  lateral  movements  can  be  made  with  it,  nor  can  it  be  raised 
from  the  surface  of  the  table,  but  the  lateral  movements  of  the 
fingers  remain  unimpaired.  The  action  of  the  flexors  is  ap- 
parently weakened,  but  the  feebleness  of  their  contractions  is 
due  to  the  fact  that  the  flexed  position  assumed  by  the  hand 
approximates  the  points  of  origin  and  insertion  of  the  flexors. 

More  or  less  anesthesia  usually  accompanies  motor  paralysis 
of  the  musculo-spiral  nerve,  and  if  the  cause  be  situated  high  up 
the  anaesthesia  affects  the  region  of  the  superior  and  inferior 
external  cutaneous  branches ;  if  lower  down,  the  dorsal  surfaces 
of  the  first  three  and  a  half  fingers,  as  far  as  to  the  second 
phalanx,  and  the  corresponding  parts  of  the  back  of  the  hand 
and  ball  of  the  thumb  are  alone  affected. 

The  extensor  muscles  are  frequently  atrophied,  and  sometimes 
a  painless  swelling  of  the  extensor  tendons  over  the  wrist-joint 
is  observed.  This  swelling  has  been  described  under  the  name 
of  tenosynitis  hyperplastica,  and  is  caused  by  the  irritation  to 
which  the  tendons  are  exposed  while  running  over  the  strongly- 
flexed  wrist.  At  times  it  may  be  the  result  of  trophic  dis- 
turbances from  the  paralysis  of  the  nerve.^ 

The  electric  excitability  is  normal  in  the  slight  cases  arising 
from  pressure  and  exposure  to  cold.  The  seat  of  the  lesion  may 
sometimes  be  accurately  ascertained  by  means  of  the  electrical 
reaction ;  thus  the  excitability  of  the  nerve  may  be  normal  below 
the  lesion,  while  no  reaction  can  be  obtained  when  the  current  is 
applied  above  it.  The  reaction  of  degeneration  occurs  in  all 
severe  traumatic  paralyses  and  in  lead  paralysis,  and  the  muscles 
present  a  high  degree  of  atrophy. 

Diagnosis. — In  paralysis  from  compression  all  the  muscles  on 
the  extensor  side  of  the  forearm  are  paralysed;  the  triceps  is 
intact;  sensory  disturbances  occur  only  in  the  hand;  and  the 
electrical   reactions    are    normal    or    only   slightly   diminished.^ 

1  Erb  (W.).    Ziemssen's  Cyclopedia.    Vol.  XI.,  1876,  p.  550. 
^  See  Bernhardt.     "Zur  Pathologie  d.  Radialsparalyse."     Arch,  f.  Psychiat., 
Bd.  IV.,  1874. 


AND  BRACHIAL  PLEXUSES.  621 

Crutch  paralysis  is  characterised  by  implication  of  the  triceps, 
by  normal  or  diminished  electrical  reactions,  and  by  exposure 
to  this  cause. 

In  severe  traumatic  paralysis  different  muscles  will  be  affected 
according  to  the  position  of  the  wound,  and  the  reaction  of 
degeneration  and  atrophy  of  the  affected  muscles  are  always 
present. 

Lead  paralysis  usually  begins  in  the  extensor  communis 
digitorum,  a  few  fasciculi  of  which  are  first  affected,  and  then 
the  whole  muscle.  The  radial  and  ulnar  extensors,  and  the 
extensors  of  the  thumb,  are  then  successively  invaded.  The 
supinator  brevis  is  only  affected  at  a  late  period  of  the  disease, 
and  the  supinator  longus  almost  invariably  escapes,  being  only 
affected  in  very  rare  cases,  and  then  at  a  late  stage  and  to  a 
very  moderate  degree,  and  only  when  the  paralysis  extends  to 
the  muscles  of  the  upper  arm.  Both  arms  are  usually  affected 
shortly  after  one  another.  The  reaction  of  degeneration  appears 
early  and  very  decidedly  in  a  part  of  the  paralysed  muscles,  and 
as  usual  it  is  associated  with  progressive  atrophy  of  the  muscle. 
In  many  cases  the  veins  of  the  forearm,  especially  those  of  the 
extensor  aspect,  are  remarkably  distended  and  varicose ;  the 
presence  of  the  blue  line  on  the  gums  will  aid  the  diagnosis. 

The  course  and  prognosis  of  the  disease  depend  upon  the 
nature  of  the  cause.  Rheumatic  paralysis  often  lasts  from  four 
to  six  weeks,  and  not  unfrequently  for  months  or  even  years, 
but  eventual  recovery  is  almost  sure.  Recovery  usually  takes 
place  in  crutch  paralysis,  under  appropriate  treatment,  in  from 
one  to  two  weeks.  Severe  traumatic  paralyses  are  as  tedious 
and  protracted  here  as  elsewhere,  and  frequently  from  half  a 
year  to  a  year  elapses  before  recovery  is  complete ;  but  unless 
an  irreparable  injury  has  been  done  to  the  nerve,  recovery  ulti- 
mately occurs. 

Lead  paralysis  is  always  slow,  months  usually  elapsing  before 
the  return  of  voluntary  motion  in  the  paralysed  muscles. 
Hysterical  paralysis  of  the  musculo-spiral  varies  very  much  in 
its  course,  like  hysterical  paralyses  in  general. 

(4)  Paralysis  in  the  Region  of  Distribution  of  the  Median 
Nerve. — Isolated  paralysis  of  the  median  nerve  from  neuritis  is 
rare,  but  occurs  more  frequently  as  the  result  of  gunshot  wounds 


622 


DISEASES   OF  THE   CERVICAL 


and  various  other  traumatic  influences.  Some  of  the  muscles 
supplied  by  the  median,  especially  those  of  the  thenar  eminence, 
are  implicated  in  progressive  muscular  atrophy. 

The  symptoms  of  paralysis  of 
the  median  nerve  are  impossi- 
bility of  pronating  the  hand, 
and  of  closing  it  to  grasp  an 
object,  with  the  exception  of 
the  two  ulnar  fingers,  which  can 
still  be  partially  bent,  because 
the  flexor  profundus  digitorum 
is  in  part  supplied  by  the  ulnar 
nerve.  Flexion  of  the  first  with 
extension  of  the  second  and 
third  phalanges  of  the  fingers 
can  be  effected  by  means  of  the 
interossei ;  and,  indeed,  there 
may  be  hyper-extension  of  the 
two  last  phalanges,  owing  to 
the  unopposed  action  of  these 
muscles.  The  patient  is  unable 
to  abduct,  oppose,  or  perform 
any  of  the  more  delicate  move- 
ments of  the  thumb,  which  is 
permanently  extended  and  ad- 
ducted,  while  its  metacarpal 
bone  is  drawn  backwards  so 
that  it  lies  on  a  plane  with  the 
metacarpal  bones  of  the  fingers, 
as  in  the  hand  of  the  monkey.^ 
Flexion  at  the  wrist  is  ac- 
companied by  adduction,  owing 
to  the  unopposed  action  of  the 
flexor  carpi  ulnaris.  The  mus- 
cles of  the  forearm  and  ball  of 
the  thumb  become  atrophied  in 
all  severe  cases. 

•  Duchenne.    Traits  relectrisation  lo- 
calisee.    Third  edit.,  1872,  p.  976. 


Fig.  99.  Superficial  Muscles  of  the  Fore- 
arm (from  Wilson). 

1,  Biceps,  with  its  tendon. 

2,  Brachialis  anticus. 

3,  Part  of  triceps. 

4,  Pronator  radii  teres. 

5,  Flexor  carpi  radialis. 

6,  Palmaris  longua. 

7,  Part  of  the  flexor  sublimis  digitorum  ; 

the  rest  of  the  muscle  is  seen  be- 
neath the  tendons  of  the  palmaiis 
longus  and  flexor  carpi  radialis. 

8,  Flexor  carpi  ulnaris. 

9,  Palmar  fascia. 

10,  Palmaris  brevis. 

11,  Abductor  poUicis. 

12,  Flexor  brevis  poUicis. 

13,  Supinator  longus. 

14,  Extensor  ossis  metacarpi  and  ex- 

tensor primi  internodii  pollicis, 
curving  round  the  lower  border 
of  the  forearm. 


AND   BRACHIAL   PLEXUSES. 


623 


Fig.  100. 


The  seusory  disorders  have  already  been  described  (§  288). 

Trophic  disturbances  of  the  skin  and  nails,  such  as  glossy 
fingers,  ulceration,  pemphigus  vesicles,  and  abnormal  growth  of 
hair,  not  imfrequently  make  their  appearance  in  paralysis  of  the 
median.  The  electrical  reactions 
are  the  same  as  in  paralysis  of 
other  nerves. 

(5)  Paralysis  in  the  Region 
of  Distribution  of  the  Ulnar 
Nerve. — Although  the  nerve, 
from  its  superficial  position  in 
the  upper  arm  and  above  the 
wrist,  is  much  exposed  to  injury, 
it  is  not  very  often  affected  with 
paralysis.  The  most  frequent 
causes  of  paralysis  of  this  nerve 
are  pressure,  contusion,  gunshot 
and  other  wounds,  fractures  of 
the  humerus,  dislocations  of  the 
shoulder,  pressure  of  crutches, 
and  sleeping  upon  the  arm  placed 
beneath  the  head.  Duchenne 
saw  paralysis  of  this  nerve  fre- 
quently in  workmen  who  rest  the 
elbow  firmly  on  a  hard  support 
in  carrying  on  their  ordinary 
occupation.  Progressive  mus- 
cular atrophy  affects  by  prefer- 
ence the  small  muscles  of  the 
hand  which  are  supplied  by  the 
ulnar.     (Table  II.,  1,  2,  3.) 

The  symptoms  of  paralysis  of 
the  ulnar  are  limitation  of  the 
power  of  ulnar  flexion  and  ad- 
duction of  the  hand ;  difficulty  or 
impossibility  of  completely  flex- 
ing the  two  last  fingers ;  loss  of 
the  power  of  moving  the  little 
finger,  of  separating  the  fingers 


Fig.  100.  Deep  Muscles  of  the  Forearm 
(from  Wilson). 

1,  Internal   lateral    ligament    of    the 

elbow  joint. 

2,  Anterior  ligament. 

3,  Orbicular  ligament  of  the  head  of 

the  radius. 

4,  Flexor    profundus    digitorum   (the 

lumbricales  removed). 
.5,  Flexor  longus  pollicis. 

6,  Pronator  quadratus. 

7,  Abductor  pollicis. 

8,  Dorsal  interosseous  of  the  middle, 

and  palmar  interosseous  of  the 
ring  finger. 

9,  Dorsal  interosseous  muscle  of  the 

ring  linger,    and    palmar   inter- 
osseous of  the  little  finger. 


624 


DISEASES   OF   THE    CERVICAL 


from  and  compressing  them  against  the  middle  finger,  and  of 
flexing  the  first  and  extending  the  second  and  third  phalanges  of 
all  the  fingers.  If  the  interossei  and  lumbricales  are  alone  para- 
lysed, the  traction  of  the  extensor  communis  and  of  the  flexors 
produces  hyperextension  of  the  first  and  flexion  of  the  two  last 
phalanges,  giving  to  the  hand  the  claw-like  appearance  which  is 
so  characteristic  of  paralysis  of  the  ulnar  nerve  above  the  wrist, 
and  of  certain  cases  of  progressive  muscular  atrophy.  The 
patient  is  also  unable  to  adduct  the  thumb  and  apply  it  firmly 
to  the  metacarpal  of  the  index  finger.  In  severe  and  protracted 
cases  the  first  phalanges  are  dislocated  backwards  upon  the 
metacarpal  bones  by  the  unantagonised  action  of  the  extensor 
communis  digitorum ;  the  second  phalanges  become  dislocated 
forwards  on  the  first,  and  the  third  on  the  second,  owing  to  the 
unantagonised  actions  of  the  flexor  digitorum  sublimis  and  pro- 
fundus respectively.  The  most  characteristic  form  of  the  claw 
hand  (main  en  griffe)  is  then  produced  {Fig.  101). 

The  use  of  the  hand  in  paralysis  of  the  ulnar  is  not  entirely 

Fig.  101. 


1.  Main  en  griffe.  2. 

Fig.  101  (after  Duchenne).  (1)  Hand,  Palmar  surface.  (2)  Dorsal  surface. — A,  Wound 
of  the  ulnar  nerve ;  B,  Ends  of  the  metacarpal  bones  ;  D,  Tendons  of  the 
flexor  sublimis  ;  0,  Muscles  of  the  ball  of  the  thumb. 


AND  BRACHIAL  PLEXUSES. 


625 


abolished,  inasmuch  as  motor  power  is  preserved  in  the  muscles 
supplied  by  the  median  nerve,  although  all  delicate  movements, 
such  as  those  required  for  writing  or  drawing  or  playing  the 
piano,  are  impaired.  But  if  the  muscles  of  the  thenar  eminence 
or  part  of  the  extensors  be  simultaneously  affected,  as  frequently 
happens,  the  use  of  the  hand  is  almost  entirely  lost. 

The  disturbances  of  sensibility  have  already  been  described 
(§  288),  and  the  electrical  reactions  of  the  paralysed  nerve  and 
muscles  present  no  special  features. 

The  atrophy  of  the  muscles  gives  to  the  hand  some  of  its 
chief  characteristics  in  paralysis  of  the  ulnar.  The  hypothenar 
eminence  is  flattened  from  atrophy  of  the  muscles  of  the  little 

Fig.  102. 


VOL.  I. 


Fia,  102.  Anterior  Surface  of  Left  Arm. 
00 


626 


DISEASES  OF  THE   CERVICAL 


finger ;  deep  furrows  appear  between  the  metacarpal  bones 
owing  to  the  disappearance  of  the  interossei;  the  metacarpal 
bone  of  the  index  finger  may  be  felt  immediately  under  the 
skin,  owing  to  the  disappearance  of  the  abductor  indicis ;  and,  if 
the  observer  grasp  the  mass  of  tissue  which  lies  between  the 
metacarpal  bones  of  the  thumb  and  index  finger,  it  will  be  felt 
to  consist  of  little  more  than  a  fold  of  skin  owing  to  the  wasting 
of  the  adductor  pollicis  and  inner  head  of  the  flexor  brevis  pollicis. 
Traumatic  lesions  of  the  ulnar  nerve  are  apt  to  give  rise  to  glossy 
fingers,  and  various  other  trophic  phenomena.  In  a  case  under 
my  care  some  time  ago  at  the  Royal  Infirmary,  the  skin  of  the 
inner  half  of  the  palm  of  the  hand  was  smooth  and  thin,  while 
that  of  the  outer  half  was  covered  by  the  callosities  always 
present  on  the  hands  of  working  people.  The  first  impulse  of 
all  to  whom  I  showed  the  case  was  to  regard  it  as  an  example 
of  hypertrophy  of  the  skin  of  the  outer  half  of  the  palm. 

(6)  Various  combinations  of  paralysis  of  the  nerves  of  the 
upper  extremity  occur,  and  each  case  must  be  specially  investi- 
gated as  it  presents  itself.  The  paralyses  which  occur  after 
dislocation  of  the  shoulder-joint  manifest  great  variety.  In  sub- 
coracoid  luxations  the  subjacent  nerve  trunks  of  the  brachial 
plexus  are  especially  liable  to  injury,  and  the  whole  of  the  nerves 
may  be  compressed  or  lacerated.      Sometimes  the  circumflex, 

Fig.  103. 


Fig.  103.  Posterior  Surface  of  Left  Arm. 


AND  BRACHIAL  PLEXUSES.  627: 

musculo-cutaneous,  and  the  three  nerve  trunks  of  the  forearm.; 
are  equally  affected;  at  other  times,  only  the  circumflex  and 
musculo-spiral  nerves  are  implicated,  and  many  other  variations 
may  occur.  Recovery  is  generally  slow,  and  the  reaction  of 
degeneration  is  exhibited  in  the  affected  nerves  and  muscles. 

In  paralysis  after  fracture  of  the  humerus,  the  result 
depends  upon  whether  one  or  more  nerve  trunks  have  been 
injured,  or  are  subsequently  implicated  in  the  formation  of  the 
callus.  The  musculo-spiral  is  most  frequently  paralysed,  then 
the  ulnar,  and  more  rarely  the  median  nerve. 

Dislocations  of  the  elbow-joint  and  fractures  in  its  vicinity, 
and  of  the  forearm,  are  often  followed  by  paralysis,  and  the 
ulnar  and  median  nerves  are  particularly  liable  to  be  affected. 
Paralysis  may  also  be  caused  by  tight  bandaging;  all  these 
paralyses  are  obstinate,  and  often  incurable. 

A  variety  of  paralysis  has  been  described  by  Straus,^  which 
implicates  all  the  naiiscles  of  the  superior  extremity  except  those 
innervated  by  the  median  nerve.  In  the  case  described  by  him, 
the  patient  on  waking  in  the  morning  complained  of  formication 
and  weakness  of  the  right  hand  and  heaviness  of  the  right  arm. 
The  weakness  extended  rapidly  until  all  the  muscles  innervated 
by  the  brachial  plexus,  except  those  supplied  by  th«  median 
nerve,  were  completely  paralysed.  The  sensory  disturbances  also 
increased  until  there  was  complete  anaesthesia  of  the  cutaneous 
surface  of  the  upper  extremity,  except  the  portions  innervated 
by  the  median  nerve.  The  electric  contractility  of  both  muscles 
and  nerves  remained  unaffected,  and  complete  recovery  took 
place  at  the  end  of  about  seven  weeks. 

(7)  Paralysis  of  tlve  Muscles  supplied  by  the  Fifth  Cervical 
Nerve. — Erb^  was  the  first  to  describe  cases  in  which  there  was 
simultaneous  paralysis  of  the  deltoid,  biceps,  brachialis  anticus, 
and  the  long  and  short  supinator  muscles.  Of  four  cases  of  this 
kind  reported  by  him,  one  was  caused  by  tumour  of  the  scapula, 
another  by  neuritis,  and  the  two  remaining  were  of  traumatic 

'  Straus  (J.).  "  Note  sur  un  cas  de  paralysie  spontan^e  du  plexus  brachial  (avec 
mt4gTit6  du  nerf  median),  et  sur  quelques  localisations  rares  de  i>aralysie  du  plexus 
brachial."    Gaz.  hebdom.,  1878,  No.  16. 

*  Erb  (W.  1.     Verhandlungen  des  naturhistorischen  Vereins  zu  Heidelberg, 

1875,  S.  130.    See  also  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,  Vol.  XI., 

1876,  p.  56L 


628 


DISEASES  OF  THE   CERVICAL 


origin.  The  muscles  were  notably  atrophied,  and  presented  the 
reaction  of  degeneration.  Similar  cases  have  been  described  by 
Remak/  Hoedemaker/  Lannois,^  and  Bernhardt.*    The  lesion 


Fig.  104. 


Branch  of  Median  Nerve  to 
Pronator  Teres 

Palmaris  Longua 


Flexor  Carpi  Ulnaris  — — 


Flexor  Snbllmia  Digitorum 

Ulnar  Nerve 
Flexor  Sublimia  Digitorum 


Volar  Nerve 
Palmaris  Brevis 

Abductor  Minimi  Digiti 

Flexor  Minimi  Digiti 

Opponens  Minimi  Digiti 

2nd,  3i'd,  and  4th  Lum-  f 
bricales  \ 


Flexor  Carpi  Eadialis 
Flexor  Profundus  Digitorum 

Flexor  Sublimis  Digitorum 


Flexor  Longus  PoUicis 
Median  Nerve 


.   Abductor  Pollicis 

Opponens  Pollicis 

Flexor  Brevis  PoUie^ 
Adductor  Pollicis 
1st  Lumbrieaiis 


Fig.  104,  Anterior  Surface  of  Left  Forearm. 

*Eemak(E.).  "  Zur  Pathologie  der  Lahmungen  des  Plexus  brachialis."  Berl. 
klin.  Wochenschrift,  1877,  No.  9. 

^  Hoedemaker  (H.  ten  Gate).  "  Ueber  die  von  Erb  zuerst  beschriebene  com- 
bjnirte  Lahmungsform,  an  der  oberen  Extremitat."  Archiv.  fiir  Psychiatrie, 
Bd.  IX.,  1879,  S.  738. 

'  Lannois.  "  Contribution  a  I'dtude  du  paralysies  spontan^es  du  plexus  bracHaL" 
Eevue  de  M^decine,  Tome  I.,  1881,  p.  996. 

*  Bernhardt  (M.).  "Beitrag  zur  Lehre  von  den  Lahmungen  im  Bereiche  des 
Plexus  brachialis."    Zeitschrift  f.  klinische  Medicin,  Bd.  iV.,  1882,  H.  3. 


AND  BEACHIAL  PLEXUSES. 


629 


must,  as  Erb  remarks,  have  been  situated  at  a  point  where 
the  fibres  forming  the  circumflex,  musculo-cutaneous,  and 
a  part  of  the  musculo-spiral  nerves,  lie  in  close  proximity. 
Hoedemaker  maintains  that  it  is  situated  in  the  cord  formed  by 
the  fifth  and  sixth  cervical  nerves,  as  it  lies  between  the  scalenus 
medius  and  posticus  muscles.  But,  as  Bernhardt  remarks,  it 
would  be  difficult  to  understand  on  this  supposition  how  the 
supra-scapular  nerves  supplying  the  supra  and  infra-spinatus 
muscles,  and  the  external  anterior  thoracic  nerve  supplying  the 
pectoralis  major,  could  escape.  It  is  therefore  more  probable 
that  the  lesion  is  situated,  as  Bernhardt  maintains,  in  the  fifth 


Supinator  Longus 
Extensor  Carpi  Radialis  Longior 

Extensor  Carpi  Radialis  Brevier 

Extensor  Communis  Digitoram-| 

Extensor  Indicis  Proprins 
Extensor   Indicis  and    Extensor 

Ossis  Metaciirpi  Pollicis 
Extensor  Ossis  Metacarpi  Pollicis 


Extensor  Brevis  Pollicis 
Extensor  Indicis 


1st  Dorsal  Interosseous 
2nd  Doisal  Interosseous     —  j--  ^ 
3rd  Dorsal  Interosseous      -'/V^W 


Flexor  Carpi  TTlnaris 


Extensor  Digiti  Minimi 


Extensor  Indicis 


Extensor  Secundi  Inter- 
nodii  Pollicis 


Abductor  Minimi  Digiti 
4tli  Doreal  Interosseous 


Fig.  105,  Posterior  Surface  of  Left  Forearm. 


630  DISEASES   OF   THE  CERVICAL 

nerve  before  its  junction  with  the  sixth  and  the  communicating 
branch  of  the  fourth  nerve.  Nearly  the  same  muscles  are  para- 
lysed in  the  form  of  paralysis  which  Duchenne^  has  described  in 
newly-born  children  under  the  name  of  "  paralysie  obstdtricale 
infantile  du  membra  superieur."  This  paralysis  always  occurs  in 
children  whose  birth  had  been  effected  by  turning,  or  some  other 
operative  procedure,  and  it  no  doubt  results  from  mechanical 
compression  applied  during  delivery.^  In  these  cases  the  arm 
hangs  immovable  by  the  side  of  the  body ;  it  is  rotated  inwards 
and  persistently  extended,  and  the  child  is  unable  to  flex  the 
forearm  or  to  raise  the  arm ;  but  the  movements  of  the  hands 
and  fingers  are  preserved.  The  deltoid,  brachialis  anticus, 
infraspinatus,  the  teres  minor,  and  probably  the  supinators,  are 
paralysed.  The  reaction  of  degeneration  is  usually  present,  and 
the  prognosis  is  unfavourable. 

Other  forms  of  paralysis  of  the  forearm  may  be  caused  by 
injuries,  such  as  dislocations,  fractures,  or  compression  of  the 
forceps. 

(8)  Paralysis  of  the  Muscles  suiyplied  hy  the  Inferior  Roots  of 
the  Brachial  Plexus. 

In  a  case  of  pachymeningitis  cervicalis  hypertrophica  reported 

Fig.  106. 


Fig.  106  (after  Charcot).  Attitude  of  the  Hand  in  Pachymeningitis  Cervicalis 
Hypertrophica,  when  the  disease  is  situated  on  a  level  with  the  lower  half  of  the 
cervical  enlargement  of  the  spijial  cord. 

*  Duchenne.    L'Electrisation  Localis^e.    1872.    p.  357. 

^  See  also  Seeligmiiller.     "  Ueber  Lahmungen,  welche  Kinder  inter  partum 
acquiriren."    Berl.  klin.  Wochenschrift,  1874,  Nos.  40  and  41. 


AND  BRACHIAL  PLEXUSES.  631 

by  Charcot/  in  which  the  lesion  was  situated  on  a  level  with  the 
seventh  cervical  and  first  dorsal  vertebrae,  the  hand  assumed 
the  position  shown  in  the  annexed  diagram  {Fig.  106),  indi- 
cating that  the  muscles  supplied  by  the  ulnar  and  median 
nerves  were  paralysed,  while  those  supplied  by  the  musculo- 
spiral  nerve  remained  comparatively  unaffected.  In  a  case  of 
this  kind  under  my  own  care  at  present,  each  hand  assumes  this 
position  when  the  patient  endeavours  to  grasp  an  object.  The 
muscles  of  the  thenar  and  hypothenar  eminences  are  atrophied. 
The  patient  is  unable  to  flex  either  hand  at  the  wrist,  to  flex  the 
fingers  at  the  metacarpo-phalangeal  joints,  to  extend  them  at 
the  phalangeal  joints,  or  to  separate  them  from  or  approximate 
them  to  the  middle  finger.  He  is  unable  to  oppose,  abduct,  or 
flex  the  thumb,  and  cannot  flex,  abduct,  or  oppose  the  little 
finger.  Pronation  and  supination  of  the  hand,  and  extension  of 
the  wrist  and  of  the  fingers  at  the  metacarpo-phalangeal  joints 
are  normally  performed.  The  distribution  of  the  anaesthesia 
in  this  case  has  already  been  described  (§  288,  and  Fig.  86). 
In  a  case  of  hsematomyelia  reported  by  me,^  in  which  the  chief 
lesion  was  situated  in  the  right  lateral  half  of  the  cord  from 
t^e  level  of  the  eighth  dorsal  up  to  that  of  the  eighth  cervical 
nerve  inclusive,  the  right  hand  assumed  the  position  figured  by 
Charcot  {Fig.  106)  when  the  patient  endeavoured  to  grasp  an 
object.  The  distribution  of  the  anaesthesia  in  this  case  is  shown 
in  Fig.  85.  These  cases  show  that  the  small  muscles  of  the  hand, 
and  the  flexors  of  the  fingers  and  wrist,  are  innervated  from  the 
inferior  roots  of  the  brachial  plexus,  most  probably  from  those 
derived  from  the  eighth  cervical  and  first  dorsal  nerves. 

(9)  Rupture  of  the  Brachial  Plexus. 

The  following  case,  kindly  sent  to  me  by  my  friend  Dr.  Cowan, 
of  Newchurch,  and  the  notes  of  which  with  the  accompanying 
diagrams  {Figs.  107  and  108)  were  taken  by  my  clinical  clerk,  Mr. 
Hall,  is  a  good  example  of  rupture  of  the  brachial  plexus  : — 

J.  F ,  aged  seventeen  years,  entered  the  Manchester  Royal  Infirmary 

on  December  2nd,  1882,  under  the  care  of  Dr.  Eoss. 

'■  Charcot  (J.  M.).  Legons  sur  les  maladies  du  systeme  nerveux.  Tome  II.,  1877, 
p.  251. 

2  Ross  (J.).    The  Practitioner.     Sept.,  1882.    p.  168. 


632[  DISEASES  OF  THE  CERVICAL 

He  never  liad  any  serious  illness  until  sis  months  before  admission  ;  at 
that  time  he  was  working  in  a  cotton  mill,  when  his  left  arm  was  caught 
between  the  strap  and  a  revolving  wheel.  His  whole  body  was  Hfted  from 
the  ground  and  he  was  carried  round  by  the  wheel  until  he  fell  on  the  oppo- 
site side.  He  was  at  first  stunned  by  the  fall,  but  on  recovering  he  felt  as 
if  his  right  arm  were  dead,  and  it  was  foimd  to  be  quite  powerless,  as  it 
has  remained  ever  since. 

Present  Condition. — The  patient  is  a  healthy  young  man,  fairly  well 
built,  and  free  from  organic  disease  of  the  internal  organs.  His  left  arm 
hangs  powerless  by  his  side  when  it  is  not  held  in  a  sling.  All  the  muscles 
of  the  upper  arm,  forearm,  and  hand  are  completely  paralysed  and 
atrophied.  The  circumference  of  the  left  arm  about  its  middle  is  6|in., 
and  of  the  right  8|in. ;  and  the  circumference  of  the  left  forearm  a  httle 
below  the  elbow  is  7in.,  and  of  the  right  9|in.  The  electrical  reactions  of 
the  nerves  of  the  brachial  plexus  are  lost.  The  faradic  contractility  of 
the  affected  muscles  is  also  abolished,  but  the  galvanic  contractihty  is 
increased,  while  a  stronger  reaction  is  obtained  from  anodal  than  from 
cathodal  closm-e.  The  latissimus  dorsi  and  the  lower  two-thirds  of  the 
pectoraUs  major  muscles  are  also  paralysed  and  atrophied,  but  the  upper 
third  of  the  pectoraHs  major  and  the  pectorahs  minor,  as  well  as  the  internal 
and  external  rotators  of  the  humerus,  are  unaffected.  The  serratus  magnus 
on  the  left  side  is  not  paralysed,  but  when  the  paralysed  arm  is  raised  ver- 
tically and  fixed  in  that  position,  the  digitations  on  the  left  are  not  so 
prominent  as  those  on  the  right  side  diiring  a  deep  inspiration,  and  there 
appears  also  to  be  a  very  shght  degree  of  relative  wasting  of  the  left  muscle, 
but  the  electrical  reactions  are  normal,  and  consequently  the  wasting  of  the 
muscle  is  most  probably  caused  by  disuse.  When  the  chest  is  at  rest  after 
the  deepest  expiration  the  left  half  on  a  level  with  the  nipple  measures 
14in.,  and  the  right  14|in. ;  and  after  the  deepest  inspiration  the  left 
measures  14|in.,  and  the  right  16|in.  The  patient  can  perform  certain 
movements  at  the  shoulder  joint  with  the  muscles  that  remain  active, 
which  might  lead  one  to  suppose,  without  careful  examination,  that 
the  deltoid,  triceps,  and  biceps  possess  a  slight  degree  of  motor  power. 
By  leaning  his  body  well  to  the  healthy  side  and  somewhat  backwards 
he  can  raise  the  arm  above  the  horizontal  level  in  a  forward  direction. 
While  in  this  position  he  can  extend  or  flex  the  forearm  upon  the  arm 
at  pleasure.  It  is  found,  however,  that  the  arm  is  raised  partly  by  a 
powerful  rotation  of  the  scapula,  in  which  the  inferior  angle  is  drawn 
well  forwards  and  the  superior  external  angle  well  tilted  upwards,  and 
partly  by  the  action  of  the  supraspinatus.  Professor  Alex.  Ogston 
examined  the  patient  along  with  me  a  few  days  ago,  and  we  were 
both  convinced  that  the  deltoid  did  not  contract  in  the  slightest 
degree  during  this  movement.  Extension  at  the  elbow  is  produced  by  a 
strong  outward  rotation  of  the  humerus,  so  that  the  forearm  falls  by  its 
own  weight  into  an  extended  position,  and  flexion  at  the  elbow  is  caused 
by  an  inward  rotation  of  the  humerus,  which  places  the  forearm  in  such  a 


AND  BRACHIAL  PLEXUSES. 


633 


position  that  it  becomes  flexed  by  the  action  of  gravity,  and  the  hand  thus 
moves  towards  and  nearly  reaches  the  patient's  mouth.  Dr.  Ogston  and 
myself  satisfied  ourselves  that  neither  the  triceps,  biceps,  brachialis  anticus, 
nor  supinator  longus  contracted  during  these  actions.  The  case  has  since 
been  examined  by  Mr.  A.  H.  Yoimg,  and  he  coincides  in  this  opinion. 

Every  form  of  sensibility  is  lost  in  the  skin  of  the  hand,  and  in  that  of 
the  forearm,  with  the  exception  of  a  small  portion  adjoining  the  elbow  in 
its  posterior  and  internal  aspects.  The  skin  of  the  inferior  half  of  the  an- 
terior surface  of  the  forearm  is  also  completely  ansesthetic ;  but  the  superior 
half  of  the  anterior  sm^face,  the  whole  of  the  skin  of  the  external,  pos- 
terior, and  internal  surfaces  of  the  arm,  is  quite  sensitive  to  the  prick  of  a 
pin,  to  pinching,  and  to  touch,  although  these  portions  of  skin  manifest  a 
shght  diminution  in  the  appreciation  of  separate  points  as  compared  with 
the  corresponding  parts  of  the  healthy  arm.  Separate  points  are  appre- 
ciated on  the  inner  surface  of  the  left  or  diseased  arm  above  the  elbow  at 
a  distance  of  3  mm.,  on  the  right  at  2  mm.,  on  the  left  arm  near  the  axilla  at 


Fig.  107. 


Fig.  108. 


Pigs.  107  and  108. — Posterior  and  anterior  aspect  respectively  of  the  arm  in  a  case 
of  rupture  of  the  brachial  plexus,  the  shaded  area  showing  the  distribution  of 
the  anaesthesia.  By  an  oversight  the  right  arm  is  represented  as  being  affected 
instead  of  the  left. 


634  DISEASES    OF  THE   CERVICAL 

6  mm.,  on  the  right  at  4  mm. ;  on  the  left  arm  over  the  shoulder  at  5  mm., 
on  the  right  at  2  mm.;  on  the  posterior  surface  of  the  left  arm  at  4  mm.,  on 
the  right  at  3  mm. ;  and  on  the  posterior  siirface  of  the  left  forearm  near 
the  elbow  at  2J  mm.,  and  on  the  right  at  If  mm.  The  distribution  of  the 
area  of  absolute  anaesthesia  is  indicated  by  the  shaded  areas  in  Figs.  107 
and  108. 

The  sensitive  area  and  that  of  absolute  anaesthesia  are  separated  by 
a  band  of  about  an  inch  in  vertical  extent,  in  which  pricking  with  a  pin 
and  strong  pinching  are  sHghtly  felt,  but  on  the  whole  the  transition  from 
one  region  to  the  other  is  comparatively  abrujit. 

The  skin  in  the  anaesthetic  area  is  thin  and  smooth  ;  the  arm  becomes 
cold  and  of  a  dark-blue  colour  on  exposm-e  ;  the  pulse  is  even  more  percep- 
tible on  the  paralysed  than  on  the  healthy  side,  but  this  most  probably 
results  from  the  wasting  of  the  tissues  in  the  former,  which  causes  the  artery 
to  feel  as  if  it  lay  almost  immediately  under  a  thin  covering  of  skin. 

The  left  pupil  is  smaller  than  the  right  in  a  diffused  light,  and  the 
difference  between  them  becomes  greater  when  the  eyes  are  shaded.  The 
left  pupil  is  dilated  to  a  medium,  and  the  right  to  a  maximum  degree  by 
atropine.  The  palpebral  fissm-e  is  decidedly  narrower,  and  the  eye  appears 
smaller  on  the  left  than  on  the  right  side.  The  colour  of  the  face  on  the  two 
sides  is  the  same,  and  the  temperature,  taken  in  the  external  meatus,  was 
found  on  an  average  of  several  observations  to  be  "8°  F.  higher  on  the  left 
than  the  right  side;  in  one  observation  the  temperature  was  slightly 
higher  on  the  right  than  on  the  left,  and  in  the  last  observation  there  was 
no  difference  between  the  two  sides. 

Dec.  19. — A  quarter  of  a  grain  of  pilocarpine  was  injected  subcu- 
taneously.  In  a  few  minutes  the  body  was  bathed  in  perspiration,  with 
the  exception  of  the  paralysed  arm,  which  remained  quite  dry.  The  left 
half  of  the  face  perspired  almost  as  freely  as  the  right  half. 

Cases  of  rupture  of  the  brachial  plexus  have  been  recorded  by 
Paget,^  Seeligmiiller,^  and  Hutchinson.'  The  accident  has  gene- 
rally been  caused  by  the  patient  falling  from  a  height  and 
grasping  some  object  during  his  fall,  by  severe  pulling  of  the 
arm  as  in  my  own  case,  or  by  the  fall  of  a  heavy  weight  on 
the  shoulder.  It  is  specially  mentioned  that  sensation  was 
preserved  in  the  inner  aspect  of  the  upper  arm  in  one  of  Paget's 
cases.  Mr.  Hutchinson  states  that,  in  one  of  his  cases,  the 
patient  had  no  sensations  below  the  elbow,  and  was  defective 
over    most   of    upper    arm    and    deltoid    region;    the   triceps 

^  Paget.    Medical  Times  and  Gazette.     March,  1869. 

^  Seeligmiiller.  "  Ueber  Sympathicus  affectionen  bei  Verletzungen  des  Plexus 
brachialis."    Berl.  klin.  Wochenschr.,  1870,  p.  313. 

^  Hutchinson.  Illustrations  of  clinical  surgery,  Vol.  I.,  p.  206;  and  Transactions 
of  the  Pathological  Society  of  London,  1880,  p.  27. 


AND  BRACHIAL  PLEXUSES.  635 

and  brachialis  anticus  muscles  are  said  not  to  have  been 
paralysed,  while  the  patient  could  flex  the  elbow  and  supinate 
the  forearm.  It  is  somewhat  difficult  to  interpret  these 
phenomena.  In  another  of  Mr.  Hutchinson's  cases  the  pulse  at 
the  wrist  was  extremely  feeble,  but  this  symptom  was  certainly 
not  present  in  my  case.  The  complete  paralysis  of  the  muscles, 
and  the  total  anaesthesia  of  the  skin  of  the  forearm  and  hand,  as 
well  as  the  oculo-pupillary  symptoms  existing  in  this  case,  show 
that  at  least  the  eighth  cervical  and  first  dorsal  nerves  are  rup- 
tured; the  total  paralysis  of  the  deltoid,  biceps,  brachialis  anticus, 
and  supinators,  shows  that  the  anterior  roots  of  the  fifth  cervical 
nerve  are  likewise  ruptured ;  and  these  conclusions  afford  a 
strong  probability  that  the  posterior  roots  of  the  fifth,  as  well  as 
the  anterior  and  posterior  roots  of  the  sixth  and  seventh  cervical 
nerves,  cannot  well  have  escaped.  It  may  therefore  be  inferred 
that  the  muscles  about  the  shoulder,  which  are  innervated  from 
the  brachial  plexus,  and  which  have  retained  their  motor  power, 
receive  their  nerve  supply  wholly  or  in  great  part  from  the  com- 
municating branch  to  the  plexus  from  the  fourth  cervical  nerve. 

Treatment  of  the  Paralyses  of  the  Upper  Extremity. — The 
removal  of  the  cause  must  be  attempted,  and  surgical  means 
are  not  unfrequently  successful.  In  rheumatic  paralysis  counter- 
irritants,  diaphoretics,  and  iodide  of  potassium  may  be  tried. 
When  neuritis  is  present  antiphlogistics  and  the  application  of 
galvanic  currents  are  useful. 

In  hysterical  and  central  paralysis  the  primary  disease  must 
be  treated.  The  treatment  of  lead  paralysis  will  be  mentioned 
in  a  subsequent  section.  In  chronic  cases  of  traumatic  paralysis 
and  in  paralysis  resulting  from  articular  rheumatism,  or  from 
chronic  neuritis,  improvement  may  be  obtained  by  the  employ- 
ment of  malt  and  mud  baths,  and  the  baths  of  Wildbad,  Teplitz, 
Wiesbaden,  &c.  Electricity  is  useful  in  the  treatment  of  all  the 
forms  of  paralysis.  In  severe  traumatic  paralysis  long-continued 
and  repeated  applications  of  the  galvanic  current  are  requisite. 
In  slight  paralysis  from  compression  faradisation  is  tolerably 
successful.  The  cervical  portion  of  the  spinal  cord  may  be 
galvanised,  while  active  and  passive  gymnastic  exercises  fre- 
quently aid  and  hasten  the  recovery. 


636 


CHAPTEE   VII. 


DISEASES    OF    THE    DORSAL    NERVES    AND    LUMBAR 
PLEXUS. 

(I.)-DISEASES    OF  THE   DOESAL   NEEVES. 

(A)  Sensory  Disorders  of  the  Dorsal  Nerves. 
(1)  Dorso-Intercostal  Neuralgia. 

§  292.  This  form  of  neuralgia  is  situated  in  the  region  of 
distribution  of  the  sensory  branches  of  the  twelve  pairs  of  dorsal 
nerves.  The  anterior  branches  of  the  nerves  usually  suffer, 
giving  rise  to  true  intercostal  neuralgia,  in  which  a  portion  of 
the  skin  of  the  anterior  and  lateral  wall  of  the  thorax  and 
abdomen  down  to  the  symphisis  pubis  may  be  affected.  When 
the  posterior  branches  are  implicated,  the  pain  affects  a  part 
of  the  skin  of  the  back  and  loins  as  far  down  as  the  crista 
ilii.  The  second  and  third  intercostal  nerves  supply  cutaneous 
branches  to  the  axilla  and  to  the  inner  surface  of  the  upper  arm, 
and  these  parts  may  occasionally  be  the  seat  of  neuralgia. 

Etiology. — Women  are  specially  liable  to  dorso-intercostal 
neuralgia.  It  comes  on  usually  between  the  ages  of  twenty  and 
forty,  in  consequence  of  over-suckling,  or  the  exhaustion  caused 
by  menorrhagia  or  leucorrhoea,  and  attacks  weak,  nervous,  hys- 
terical, and  anaemic  subjects. 

The  exciting  causes  are  exposure  to  cold,  and  injuries  of  various 
kinds,  while  in  other  cases  the  neuralgia  is  a  symptom  of  disease 
of  the  nerves,  such  as  neuritis  and  neuromata.  Disease  in  the 
neighbourhood  of  the  nerves  may  also  give  rise  to  intercostal 
neuralgia,  the  most  usual  of  these  being  aortic  aneurisms,  disease 
of  the  vertebrae  or  of  the  ribs,  pulmonary  phthisis,  and  dilatation 
of  the  venous  plexus   in  the  interior  of  the  vertebral  canal. 


DISEASES  OF  DORSAL  NERVES  AND  LUMBAR  PLEXUS,       637 

Diseases  of  the  spinal  cord,  such  as  circumscribed  myelitis, 
spinal  meningitis,  tumours  in  the  vertebral  canal  and  spinal  cord, 
and  locomotor  ataxy,  are  frequently  associated  with  intercostal 
neuralgia. 

SymiJtoms. — In  intercostal  neuralgia  there  is  a  dull,  tensive, 
and  continuous  pain,  which  is  sometimes  interrupted  by 
paroxysms  of  tearing,  lancinating,  or  burning  pains.  All  violent 
respiratory  movements,  such  as  sneezing,  aggravate  the  pain, 
so  also  does  slight  pressure  on  the  skin,  such  as  that  of  the  bed- 
clothes, but  steady  firm  pressure  often  relieves  it.  The  pain  not 
unfrequently  radiates  towards  the  back  and  arm  or  into  the  loins 
or  lower  extremities,  Dorso*intercostal  neuralgia  is  generally 
unilateral,  and  the  area  of  distribution  of  one  or  two  branches 
on  the  left  side  from  the  fifth  to  the  ninth  nerve  is  the  part 
most  frequently  affected.  This  form  of  neuralgia  may  be  com- 
bined with  brachial  and  lumbo-abdominal  neuralgia,  or  with 
angina  pectoris.  Hypercesthesia  of  the  affected  skin  is  common, 
and  ancBsthesia,  which  is  usually  limited  to  a  small  circumscribed 
area,  has  been  observed.  Motor  phenomena,  which  interfere  to 
some  extent  with  respiration,  are  generally  present. 

The  painful  points  are  :  (1)  A  vertebral  point  close  to  the  vertebral 
column,  where  the  nerve  emerges  from  the  intercostal  foramen  ;  (2)  a 
lateral  poi7it,  where  the  lateral  perforating  branch  becomes  subcutaneous, 
midway  in  the  intercostal  space ;  and  (3)  an  anterior  or  sternal  point,  where 
the  anterior  perforating  branch  pierces  the  muscles  close  to  the  sternum 
and  in  the  abdomen  over  the  rectus  muscle.  The  whole  length  of  the  in- 
tercostal nerves  and  several  of  the  spines  of  the  corresponding  vertebrae  are 
frequently  extremely  sensitive  and  tender. 

Of  the  vaso-motor  and  trophic  disturbances,  herpes  zoster  is 
the  best  known,  although  its  relations  to  neuralgia  are  by  no 
means  constant.  Herpes  zoster  is  seldom  attended  by  severe 
neuralgia  in  young  persons,  but  in  old  persons  the  neuralgia 
generally  precedes  and  outlasts  the  herpes. 

The  course  of  intercostal  neuralgia  is  irregular,  but  it  is 
usually  obstinate,  and  recovery  is  very  gradual.  The  neuralgia 
which  is  caused  by  disease  of  the  spinal  cord  or  of  its  mem- 
branes is  always  obstinate  and  sometimes  incurable,  while  in 
such  affections  as  pulmonary  phthisis  and  disease  of  the  vertebrae, 
the  neuralgia  generally  terminates  only  with  death. 


638  DISEASES   OF  THE  DORSAL  NERVES 

Diagnosis. — The  diagnosis  of  dorso-intercostal  neuralgia  is 
surrounded  with  considerable  difficulties.  It  is  liable  to  be 
confounded  with  myalgia,  either  pleurodynia  or  lumbago.  The 
seat  of  the  pain  in  certain  muscles,  its  aggravation  on  movement 
and  on  pressure,  the  absence  of  painful  points,  and  the  rapid 
recovery  in  the  course  of  a  few  days,  serve  to  distinguish  pleuro- 
dynia and  lumbago  from  intercostal  neuralgia.  Diseases  of  the 
thoracic  organs  must  be  distinguished  from  neuralgia  by  physical 
examination.  Angina  pectoris  resembles  intercostal  neuralgia  in 
some  respects;  but  the  intense  anxiety  and  feeling  of  impending 
death,  along  with  the  characteristic  radiation  of  the  pain,  should 
prevent  the  diseases  from  being  confounded. 

(2)  Mastodynia. 

Neuralgia  of  the  female  breast  forms  a  special  variety  of 
intercostal  neuralgia.  The  skin  over  the  mammae  is  supplied 
by  the  lateral  and  anterior  perforating  branches  of  the  second 
to  the  sixth  intercostals,  and  by  minute  branches  of  the  supra- 
clavicular nerves,  whilst  the  proper  substance  of  the  gland  is 
supplied  by  the  lateral  perforating  branches  of  the  fourth,  fifth, 
and  sixth  intercostals.  Neuralgia  of  the  breast  may  appear  in 
those  who  have  a  strong  neurotic  tendency,  along  with  the 
first  development  of  the  breasts  at  puberty,  especially  when 
puberty  is  prematurely  developed  in  consequence  of  self-abuse. 
Neuralgic  pain  may  come  on  during  pregnancy,  although  a  large 
proportion  of  the  pains  felt  in  the  mammary  gland  during  this 
period  are  caused  by  mechanical  distension  of  the  breast. 
Neuralgia  frequently  follows  shrinking  of  the  nipples,  and  the 
irritation  of  cracked  nipples  may  be  the  exciting  cause  of 
attacks  of  the  disease.  Anaemia,  chlorosis,  and  hysteria  also 
take  a  great  part  in  the  production  of  the  disease.  Injuries  of  the 
gland,  neuromata,  or  painful  tubercles  of  the  nerves,  may  like- 
wise be  the  starting  points  of  neuralgia.  The  pain  of  "irritable" 
breast  is  very  violent,  and  described  as  tearing,  cutting,  boring, 
and  lancinating ;  it  appears  in  paroxysms,  which  are  usually  of 
short  duration,  but  may  last  several  hours.  The  breast  feels 
heavy,  and  the  patient  cannot  lie  on  the  affected  side ;  the 
slightest  contact,  even  the  pressure  of  the  clothes,  is  unbear- 
able. 


AND  LUMBAR  PLEXUS.  639 

Patnfxd  points  may  be  found  on  the  nipple  or  on  the  sides  of  the  breast, 
but  they  are  indefinite  ;  and  the  spinous  processes  of  the  second  to  the 
sixth  dorsal  vertebrse  are  usually  tender  on  pressure.  There  is  generally  a 
great  deal  of  hyperaesthesia,  and  the  paroxysms  are  sometimes  accompanied 
by  vomiting.  The  pain  radiates  into  adjoining  regions,  and  the  severity  of 
the  paroxysms  is  increased  during  the  catamenial  period. 

Treatment. — The  general  principles  of  treatment  of  dorso- 
intercostal  neuralgia  are  the  same  as  for  other  forms  of  the 
disease.  Counter-irritation  is  very  valuable,  especially  in  the 
form  of  flying  blisters  applied  in  succession  over  the  painful 
points,  but  as  a  rule  preference  should  be  given  to  the  milder 
cutaneous  irritants  and  to  anodyne  embrocations.  The  faradic 
current  may  be  used  as  a  cutaneous  irritant  in  the  form  of  the 
brush  or  moxa.  In  using  the  galvanic  current,  the  cathode 
should  be  placed  on  the  vertebral  column,  and  the  anode  upon 
the  lateral  and  anterior  painful  points ;  the  current  should  be 
strong  and  stabile.  Subcutaneous  injection  of  morphia  is,  as 
usual,  a  valuable  agent  in  the  treatment. 

When  herpes  zoster  is  associated  with  neuralgia,  the  surface 
should  be  covered  by  some  indifferent  and  protective  ointment 
or  plaster,  to  which  some  narcotic  may  be  added.  Cotton  wool 
also  makes  an  admirable  protective  covering.  Flying  blisters 
may  be  applied  to  the  side  of  the  vertebral  column,  as  recom- 
mended by  Dr.  Anstie ;  in  a  case  in  which  a  woman  took  the 
treatment  out  of  my  hands  and  applied  a  large  blister  over  the 
vesicles,  complete  and  immediate  relief  was  afforded. 

The  treatment  of  mastodynia  is  not  very  successful.  The 
causes  of  the  disease,  as  anaemia  and  disturbance  of  the  gene- 
rative organs,  must  be  combated.  A  belladonna  plaster  may  be 
found  useful  along  with  the  usual  remedies,  such  as  anodynes, 
electricity,  and  tonics.  The  breast  may  be  enveloped  in  cotton 
wool,  fur,  or  any  other  soft  and  warm  covering.  Removal  of 
painful  indurations  and  amputation  of  the  breast  should  only 
be  undertaken  as  a  last  resort. 

(B)  Motor  Disorders  of  the  Dorsal  N'ei^es. 

The  spasmodic  affections  of  the  dorsal  nerves  have  already 
been  considered  along  with  those  of  the  cervical  plexus  (§  284) ; 


640  DISEASES  OF  THE  DOKSAL  NERVES 

it  only  remains  for  us  at  present  to  consider  paralysis  of  the 
dorsal  muscles. 

Paralysis  of  the  Dorsal  Muscles. 

§  .293  Paretic  and  paralytic  conditions  of  the  extensors  of 
the  back  are  not  uncommon.  Various  degrees  of  weakness  of  the 
dorsal  muscles  are  often  present  in  young  people,  sometimes  on  one 
and  sometimes  on  both  sides,  giving  rise  to  various  forms  of  spinal 
curvature.  Rheumatic  affections  may  cause  paralysis  of  one  or 
several  of  the  dorsal  muscles,  and  the  same  result  may  super- 
vene upon  iojuries  of  the  back.  Paralysis  of  the  dorsal  muscles 
is  rare  in  cerebral  disease,  but  is  not  unfrequent  in  spinal 
affections.  Progressive  muscular  atrophy  not  unfrequently  ex- 
tends to  the  dorsal  muscles,  and  weakness  of  the  long  extensors 
of  the  back  forms  a  characteristic  feature  of  pseudo-hypertrophic 
paralysis.  Occasionally  weakness  with  atrophy  of  these  muscles 
occurs  in  young  persons  without  any  obvious  cause. 

The  muscles  principally  affected  are  the  sacro-lumbalis  and 
the  longissimus  dorsi,  with  their  continuations  towards  the  neck 
and  head,  and  the  small  muscles  between  the  several  vertebrae. 
We  ought  to  determine  clinically  whether  the  paralysis  has 
its  seat  in  the  lumbar,  dorsal,  or  cervical  portion.  When  the 
extensors  of  the  dorsal  region  on  both  sides  are  paralysed  the 
vertebral  column  forms  a  large  and  equable  curve,  the  patients 
appear  bent  and  doubled  up  as  in  old  age,  and  are  unable  to 
hold  themselves  erect,  but  passive  straightening  of  the  vertebral 
column  can  be  effected  with  tolerable  facility,  and  this  distin- 
guishes paralytic  kyphosis,  as  the  condition  is  called,  from  the 
kyphosis  which  results  from  muscular  contracture  or  disease  of 
the  vertebrae.  If  the  paresis  or  paralysis  be  unilateral,  various 
forms  of  paralytic  scoliosis  are  produced. 

Paralysis  of  the  extensors  in  the  lumbar  region  presents  very 
characteristic  features.  The  lumbar  vertebrae  are  curved  inwards 
so  as  to  form  a  remarkable  hollow  in  the  back — a  hollow  which 
is  increased  bj?  the  upper  part  of  the  body  being  thrown  back- 
wards in  order  to  compensate  for  the  incurvation  of  the  lumbar 
portion.  A  plumb  line  allowed  to  drop  from  the  most  prominent 
spinous  process  of  the  dorsal  vertebrae  clears  the  sacrum  gene- 
rally by  one  to  one  and  a  half  inches.     The  further  peculiarities 


AND  LUMBAE  PLEXUS.  641 

of  this  variety  of  paralysis  will  be  described  when  we  come  to 
discuss  pseudo-hypertrophic  paralysis. 

If  the  posterior  muscles  of  the  nech  are  alone  paralysed,  the 
head  can  do  longer  be  carried  erect,  but  the  patient  can  raise  it 
by  a  peculiar  swinging  movement,  and  he  then  usually  carries  it 
inclined  backwards,  supported  only  by  the  anterior  muscles  of 
the  neck. 

Paralysis  of  the  abdominal  miLScles  is  very  rare  as  an  iso- 
lated affection,  but  is  a  common  symptom  of  spinal  paralysis, 
and  occurs  occasionally  in  progressive  muscular  atrophy.  When 
the  paralysis  is  unilateral,  the  umbilicus  is  carried  to  the  sound 
side  with  each  movement  of  forcible  expiration.  When  the 
paralysis  is  bilateral,  all  expiratory  efforts  are  enfeebled,  and 
expiratory  reflex  acts,  such  as  coughing  and  sneezing,  are  ren- 
dered ineffective. 

The  power  of  compressing  the  abdomen  is  impaired,  causing 
difficulty  of  evacuating  the  contents  of  the  rectum  and  bladder. 
The  abdomen  is  large  and  protuberant ;  its  walls  are  relaxed  ;  and 
the  patient  is  unable  to  raise  the  upper  part  of  the  body  from 
the  recumbent  position,  or  to  sit  in  bed  without  being  propped 
up  by  the  hands.  In  walking  or  standing  the  upper  part  of  the 
body  is  bent  slightly  forwards  and  balanced  exclusively  by  the 
lumbar  muscles,  and  consequently  each  backward  movement  of 
the  centre  of  gravity  renders  the  patient  liable  to  fall  on  his 
back,  because  the  abdominal  muscles  are  incapable  of  drawing 
the  trunk  forwards.  When  paraplegia  is  present  this  symptom 
cannot  be  determined. 

Treatment. — The  treatment  must  depend  on  the  nature  of 
the  primary  disease,  of  which  the  paralysis  is  but  a  symptom. 
Electrical  treatment  is  of  great  advantage,  and  both  the  gal- 
vanic and  faradic  currents  may  be  useful. 

When  the  paralysis  is  incomplete,  benefit  is  sometimes  ob- 
tained by  a  system  of  gymnastics ;  in  incurable  cases  appropriate 
orthopcedic  apparatus  may  be  employed  to  replace  the  deficient 
muscular  action.  The  employment  of  embrocations,  baths, 
douches,  liniments,  massage,  change  of  air,  and  general  tonic 
treatment  is  productive  of  good  results. 


VOL.  I.  PP 


6  42  DISEASES  OF  THE  DORSAL  NERVES 

(II.)--r>ISEASES    IN    THE    REGION    OF    DISTRIBUTION    OF    THE 
LUMBAR   NERVES. 

(A)  Sensory  Disorders  of  the  Lumbar  Plexus. 
Lumbar  Neuralgia. 

§  294.  This  form  of  neuralgia  includes  all  varieties  having 
their  seat  in  the  region  of  distribution  of  the  first  four  pairs  of 
lumbar  nerves.  The  following  are  the  regions  supplied  by  these 
nerves : — The  region  of  the  loins  supplied  by  the  posterior 
branches  of  these  nerves;  the  gluteal  region,  inguinal  region, 
hypogastrium,  and  mons  veneris,  part  of  the  scrotum  in  the 
male,  and  of  the  labia  majora  in  the  female,  the  anterior  lateral 
and  median  surface  of  the  thigh,  the  anterior  region  of  the  knee 
joint,  the  median  surface  of  the  leg,  and  the  inner  border  of  the 
foot  as  far  as  to  the  great  toe. 

Etiology. — The  causes  of  this  form  of  neuralgia  are  not  well 
known.  Dr.  Anstie  mentions  a  well-marked  instance  of  the 
disease  which  was  excited  by  sudden  fright  in  a  woman  ex- 
hausted by  leucorrhoea,  and  with  a  decided  neuropathic  history. 
Exposure  to  cold,  injuries,  neuromata,  and  other  tumours,  com- 
pression of  nerves  from  hernise,  or  from  accumulation  of  faeces, 
cancer  in  the  pelvis  or  the  vertebral  column,  diseases  of  the 
vertebrae,  psoas  abscesses,  diseases  of  the  uterus  and  vagina, 
have  each  been  ascertained  to  have  formed  the  exciting  cause 
of  the  disease.  Spinal  diseases,  as  meningitis,  myelitis,  and 
tabes  dorsalis,  are  also  causes  of  the  disease;  and  the  pain  of 
the  knee  in  coxitis  is  a  neuralgia  caused  by  reflex  irritation. 

Symptoms. — It  is  very  rare  for  the  whole  of  the  branches  of 
the  lumbar  plexus  to  be  implicated ;  and,  as  a  rule,  only  one  or 
a  few  branches  are  affected.  The  disease  may  be  divided  into 
neuralgia  (1)  of  the  "short"  nerves  of  the  lumbar  plexus,  and 
which  from  its  situation  may  be  called  lunfibo-ahdominal 
neuralgia;  and  (2)  of  the  "long"  nerves  of  the  plexus,  which 
may  be  termed  femoral  neuralgia.  The  external  generative 
organs  and  neighbouring  parts  are  supplied  by  branches  from 
the  sacral  nerves,  as  well  as  from  the  lumbar  plexus,  but  it  will 
be  more  convenient  to  describe  the  different  forms  of  neuralgia 
to  which  those  parts  are  liable  in  this  place. 


AND  LUMBAR  PLEXUS.  643 

(1)  Lumbo-ahdominal  Neuralgia. 

There  is  pain  in  the  loins  extending  over  the  crista  ilii  as 
far  as  the  buttock,  with  pain  in  the  hypogastrium,  mons  veneris, 
and  scrotum  or  labia  majora.  The  inguinal  region  may  be 
affected  at  the  same  time,  although  this  is  not  usual. 

The  Painful  Points  are  :  (1)  Vertebral  points,  corresponding  to  the  pos- 
terior branches  of  the  respective  nerves  ;  (2)  Iliac  point,  corresponding  to 
the  middle  of  the  crista  ilii ;  (3)  Abdominal  points  above  the  symxDhysis 
pubis  at  the  side  of  the  linea  alba ;  (4)  An  inguinal  point  in  the  groin, 
near  the  exit  of  the  spermatic  cord,  from  whence  the  pain  radiates  along 
the  latter  ;  (5)  A  scrotal  or  labial  point  situated  in  the  scrotum  or  labium 
majus.  The  pain  frequently  radiates  into  neighbouring  nerve  territories, 
and  especially  into  those  suppUed  by  the  crural  and  intercostal  nerves ; 
and  it  is  probable  that  the  sympathetic  plexuses  of  the  pelvic  organs  are 
often  impHcated.  Spasm  of  the  cremaster,  vomiting,  herpes,  increased 
sexual  desire,  vrith  priapism  and  ejaculation  of  seminal  fluid,  may  be  men- 
tioned as  the  most  usual  of  the  concomitant  symptoms  of  this  variety  of 
nemalgia. 

(2)  Femoral  Neuralgia  may  be  subdivided  into  three 
varieties :  (a)  Neuralgia  of  the  lateral  cutaneous  nerve  of  the 
thigh  ;  (6)  crural  neuralgia  ;  and  (c)  obturator  neuralgia. 

(a)  Neuralgia  of  the  Lateral  Cutaneous  Nerve  of  the  Thigh. 
The  pain  extends  down  along  the  outer  and  part  of  the  posterior 
aspect  of  the  thigh  as  far  as  the  knee.  A  constant  painful  spot 
is  present  over  the  anterior  superior  spinous  process  of  the  ilium, 
where  the  nerve  emerges  from  the  pelvis,  and  less  constant  spots 
may  be  present  along  the  outer  side  of  the  thigh. 

(6)  Crural  Neuralgia. — The  middle  and  inner  part  of  the 
anterior  surface  of  the  thigh,  the  anterior  surface  of  the  knee, 
the  inner  surface  of  the  leg,  and  of  the  foot  as  far  as  to  the 
great  toe  are  affected. 

The  painful  points  associated  with  this  variety  are  :  (1)  One  in  the  fold 
of  the  groin  when  the  nerve  emerges  from  the  pelvis  ;  (2)  the  inner  side  of 
the  knee-cap  when  the  saphenous  nerve  appears  beneath  the  skin ;  (3)  in 
front  of  the  ankle-joint  ;  (4)  at  the  base  of  the  great  toe. 

Amongst  the  concomitant  symptoms  may  be  mentioned  hyper- 
sesthesia  of  the  skin,  especially  in  the  vicinity  of  the  knee-joint, 
or  anaesthesia  of  part  of  the  surface,  and  a  feeling  of  numbness 
or  formication  in  the  region  of  distribution  of  the  saphenous 


644* 


DISEASES  OF  THE  DORSAL  NERVES 

Fig.  109. 


Fig.  109.  Lumbar  PUjcus. 

IL,  IIL,  IIIL,  and  IVL.— The  first,  second,  third,  and  fourth  lumbar  nerves, 

respectively. 
D,  Communicating  branch  from  the  last  dorsal  nerve. 
CCCC,  Posterior  cutaneous  branches. 
mmmm,  Branches  to  the  muscles  of  the  back. 
Ill,  Ilio-hypogastric  nerve. 

I,  Iliac  branch  cutaneous  to  surface  of  gluteal  region. 

H,  Hypogastric  branch  cutaneous  to  surface  of  hypogastric  region. 
1,  Muscular  branch  to  obliquus  internus. 
1',  Rectus  abdominis. 

II,  Ilio-inguinal  nerve  cutaneous  to  inguinal  region  and  scrotum. 
GO,  Genito-crural  nerve. 

G,  Genital  branch  to  spermatic  cord  or  round  ligament. 

2,  Muscular  branch  to  cremaster. 
0,  Crural  branch,  cutaneous  to  surface  of  upper  part  of  front  of  thigh. 


AND  LUMBAR  PLEXUS.  645 

nerve.  There  may  be  also  weakness  and  paresis  of  the  muscles 
of  the  thigh,  and  the  patient  complains  of  weariness. 

(c)  Obturator  Neuralgia. — The  pain  in  this  variety  is  con- 
fined to  the  inner  side  of  the  thigh,  extending  as  far  as  the 
knee-joint.  Formication  on  the  inner  surface  of  the  thigh,  and 
a  feeling  of  stiffness  and  immobility  of  the  adductors,  are 
usually  present.  This  form  of  neuralgia  is  associated  with 
obturator  hernia,  and  Romberg  has  pointed  out  that  when 
obturator  neuralgia  is  present  along  with  symptoms  of  strangu- 
lated intestines,  obturator  hernia  may  safely  be  inferred. 

The  course  of  all  the  varieties  of  femoral  neuralgia  is,  as  a 
rule,  favourable,  and  its  duration  short,  except  in  cases  associated 
with  grave  organic  disease. 

The  diagnosis  is  not  unattended  with  difficulty.  It  may  be 
confounded  with  myalgia,  especially  with  lumbago.  In  the  latter 
disease  the  pain  is  usually  circumscribed,  and  does  not  radiate 
in  various  directions ;  it  is  generally  aggravated  by  stretching 
the  body  or  raising  a  weight,  and  disappears  when  rest  in  the 
recumbent  posture  is  maintained.     The  pain  of  renal  calculi 


EC,  External  cutaneous. 

P,  Posterior  branch  cutaneous  to  upper  and  outer  part  of  thigh. 

A,  Anterior  branch  cutaneous  to  front  of  thigh. 

pg.  Muscular  branches  to  psoas  muscle. 
AC,  Anterior  crural  nerve. 

3,  Muscular  branches  to  iliaeus. 
3',  ,,  „  sartorias^ 
3",         „             ,,  pectineus. 
fa,  Branch  to  femoral  artery. 

MC,  Middle  cutaneous  to  front  of  thigh. 

IC,  Internal  cutaneous  to  inner  part  of  thigh  asd  leg. 

LS,  Internal  or  long  saphenous. 

a.  Cutaneous  over  inner  ankle. 

/,  „         to  inner  side  of  foot, 

4,  Muscular  branch  to  rectus  femoris. 
4',  „  ,,  vastus  externus. 
4",         ,,            „  crureus. 

4'",         ,,  ,,  subcrureus. 

4"",        „  ,,  vastus  internus. 

Kj,  Branch  to  knee-joint. 
0,  Obturator  nerve. 

hj,  Branch  to  hip-joint. 

c',   Communicating  with   branches  of    internal  cutaEeous   and   internal 
saphenous, 

5,  Muscular  branch  to  pectineus. 

5',  ,,  „  obturator  externus. 

6,  ,,  „  adductor  longus. 
6',          ,,            ,,            gracilis. 

6",         „  „  adductor  brevis. 

6'"  6"",  „  „  adductor  magnus. 

Kf,  Branch  to  knee-joint. 
L,  Communicating  branch  to  fifth  lumbar  nerve. 


646  DISEASES   OF  THE   DOESAL   NERVES 

often  cannot  be  distinguished  from  neuralgia,  and  the  diagnosis 
from  hip  and  knee-joint  diseases  requires  care  and  circumspection. 

(3)  Neuralgia  of  the  External  Generative  Organs  and 
Adjacent  Parts. 

The  external  organs  of  generation  receive  their  chief  nervous 
supply  from  the  sacral  plexus  by  means  of  the  dorsal  and 
superficial  perinseal  branches  of  the  internal  pudic  nerve,  and 
the  inferior  or  long  pudendal  branch  of  the  small  sciatic  nerve  ; 
the  integument  in  the  region  of  the  anus  is  supplied  by  the 
inferior  hemorrhoidal  branches  of  the  pudic  nerve,  and  by 
branches  from  the  fourth  and  fifth  sacral  nerves.  The  lumbar 
plexus,  however,  contributes  to  the  nervous  supply  of  these 
organs,  inasmuch  as  the  supra-pubic  region,  and  the  upper  part 
of  the  scrotum  or  labium  pudendi,  receive  branches  from  the 
ilio-hypogastric  and  ilio-inguinal  nerves.  The  spermatic  cord 
and  cremaster  or  round  ligament  is  supplied  by  the  genital 
branch  of  the  genito-crural  nerve.  Sympathetic  filaments  from 
the  hypogastric  plexus  pass  to  the  penis  and  prostate  gland ; 
while  the  testicle  receives  branches  both  from  the  hypogastric 
and  spermatic  plexuses.  The  vagina  receives  branches  from  the 
hypogastric  plexus,  and  is  also  supplied  by  the  fourth  sacral  and 
pudic  nerves. 

The  external  genitals  may  participate  in  neuralgia  affecting 
various  nerve  regions,  but  isolated  neuralgia  of  the  genitals  is 
sometimes  met  with.  In  the  latter  kind  of  cases  several  nerve- 
regions  are  usually  affected,  so  that  it  is  difficult  to  determine 
the  particular  nerves  implicated.  The  following  varieties  are 
met  with : — 

(ct)  Neuralgia  of  the  Penis  and  Mons  Veneris. — The  pain 
has  its  seat  in  the  glans,  and  extends  to  the  root  of  the  organ. 
The  pain  is  violent,  lancinating,  and  burning,  and  may  be  uni- 
lateral or  bilateral;  it  is  increased  by  sexual  intercourse  and 
urination,  and  it  may  be  accompanied  by  priapism  and  frequent 
ejaculations. 

(6)  Neuralgia  Scrotalis  (et  labialis)  is  a  common  symptom 
of  lumbo-abdorainal  neuralgia.  The  scrotum  or  labium  majus 
is  often  very  tender  to  the  touch. 


AND   LUMBAR  PLEXUS.  647 

(c)  Neuralgia  Urethralis  is  characterised  by  pain  in  the 
urethra  during  micturition,  and  increased  desire  to  urinate.  It 
is  sometimes  an  early  symptom  of  tabes  dorsalis,  but  may 
arise  from  exposure  to  cold,  or  from  morbid  conditions  of  the 
urine. 

{d)  Neuralgia  Spermatica  is  characterised  by  violent  inter- 
mitting pain  in  the  testis  and  epididymis,  which  radiates  along 
the  spermatic  cord  and  down  the  thigh.  In  what  has  been 
described  by  Sir  Astley  Cooper  as  "  irritable  testis "  the  parts 
become  extremely  sensitive  to  pressure,  and  are  liable  to 
periodic  enlargement.  The  attack  is  frequently  accompanied 
by  vomiting  and  general  malaise.  The  affection  chiefly  occurs 
in  young  people,  and  is  usually  unilateral.  Some  regard  this 
form  of  the  disease  as  a  variety  of  lumbo-abdominal  neuralgia, 
but  the  opinion  is  now  gaining  ground  that  it  is  the  sympathetic 
nerves  which  are  chiefly  implicated. 

(e)  Neuralgia  Ano-vesi'calis  consists  of  morbid  sensations  in 
the  region  of  the  coccyx,  associated  with  hypersesthesia  or  anaes- 
thesia of  the  skin  of  the  periaseal  region,  spasm  of  the  sphincter 
ani  and  of  the  muscles  of  the  urethra  and  bladder,  and  difii- 
culty  of  micturition.  It  occurs  in  patients  suffering  from  tabes 
dorsalis,  and  may  be  caused  by  onanism  and  excessive  sexual 
indulgence. 

Treatment — The  treatment  of  lumbar  neuralgia  presents 
nothing  special.  Flying  blisters,  injection  of  morphia  or  of 
atropine,  and  electricity,  appear  to  give  the  best  results.  A 
descending  stabile  current  may  be  made  to  pass  from  the  lumbar 
region  of  the  vertebral  column  through  the  affected  nerve.  The 
milder  forms  of  neuralgia  of  the  external  generative  organs 
usually  yield  to  the  ordinary  treatment  for  neuralgia,  whilst  the 
severer  forms  prove  most  intractable  to  all  kinds  of  treatment. 
Narcotics,  in  the  form  of  subcutaneous  injection,  and  supposi- 
tories are  useful  and  often  necessary  parts  of  the  treatment. 
Specifics,  such  as  arsenic,  quinine,  and  oil  of  turpentine,  often  do 
good.  Electric  treatment  has  not  yet  been  sufficiently  tried,  but 
the  constant  current  should  undoubtedly  form  part  of  the  treat- 
ment. In  spermatic  neuralgia  operative  proceedings  and  even 
castration  have  been  had  recourse  to. 


648 


DISEASES  OF  THE  DORSAL  NERVES 


Fig.  110. 


(B)  Motor  Disorders  of  the  Lumbar  Plexus. 

(1)  Spasm  in  the  Muscles  supplied  by  the  Lumbar  and  Sacral 

Nerves. 

§  295.  (a)  Spastic  contracture  of  the  hip  was  first  described 

by  Stromeyer.  It  consists  of  a 
tonic  spasm  of  the  psoas  and 
iliacus,  of  the  quadratus  lum- 
borum,  and  occasionally  of  one 
or  two  of  the  muscles  of  the 
front  of  the  thigh.  The  extre- 
mity is  bent  at  the  hip-joint, 
the  tendon  and  muscular  belly 
of  the  ilio -psoas  muscle  project 
strongly,  the  pelvis  appears  to 
be  raised  on  the  affected  side, 
the  limb  is  shortened,  and  in 
walking  the  patient  inclines  to 
that  side.  Any  attempt  to 
extend  the  limb  causes  acute 
pain  in  the  tense  muscles,  and 
also  in  the  knee.  This  affection 
is  usually  caused  directly  by 
disease  of  the  lumbar  vertebrse 
with  psoas  abscess,  and  in  a 
reflex  manner  by  disease  of  the 
hip-joint. 

(&)  Spasm  of  the  quadriceps 
extensor  femoris  is  rare.  Tonic 
spasm  of  this  muscle  gives  rise 
to  rigid  extension  of  the  leg  on 
the  thigh,  such  as  is  observed 
in  tetany  and  in  neuralgia  of 
the  knee-joint.  Clonic  convul- 
sion of  the  muscle  was  ob- 
served by  Erb  whenever  the 
patella  was  touched  in  a  case 
of  articular  hypersesthesia. 

(c)  Contracture  of  the  ad- 
ductors of  both  thighs  has  been 


Fig.  110.  Muscles  of  the  Antei-ior  Femoral 
Region  (after  Heath). 

3,  Crest  of  the  ilium. 

2,  Its  anterior  superior  spinous  process. 

3,  Gluteus  medius. 

4,  Tensor  vaginse  femoris  ;  its  inser- 

tion into  the  fascia  lata  is  shown 
inferiorly. 

5,  Sartor ius. 

6,  Rectus  femoris. 

7,  "Vastus  externus. 

8,  Vastus  internus. 

9,  Patella. 

10,  Iliacus  internus. 

11,  Psoas  magnus. 

12,  Pectineus. 

13,  Adductor  longus. 

14,  Part  of  the  adductor  magnus. 

15,  Gracilis. 


AND  LUMBAR  PLEXUS. 


649 


observed  by  Reitter,  caused  probably  by  rheumatic  inflammation 
of  both  hip-joints.     It  also  occurs  as  a  symptom  of  tetany. 


(2)  Paralysis  of  the  Muscles  supplied  by  the  Lumbar  axd  Sacral 

Nerves. 

§  296.  (a)  Paralysis  in  the  Region  of  Distribution  of  the 
Crural  Nerve. — The  crural  nerve  supplies  the  iliacus,  the 
quadriceps     extensor     femoris, 


the  sartorius,  and,  in  part,  the 
pectineus. 

Paralysis  of  this  nerve  arises, 
from  injuries  of  the  vertebral 
column  and  pelvis,  from  tumours, 
and  extravasations  of  blood  in 
the  Cauda  equina,  but  it  is  rare 
as  an  isolated  affection.  It  may 
follow  inflammation  of  the  knee- 
joint,  and  also  occurs  in  conse- 
quence of  psoas  abscess,  in  which 
case  it  is  preceded  by  symp- 
toms of  irritation.  It  may  be 
caused  by  fractures  of  the  thigh 
and  dislocation  of  the  hip-joint, 
wounds  and  various  other  in- 
juries of  the  lower  abdominal 
and  crural  regions,  neuritis,  and 
by  pelvic  and  crural  tumours ; 
it  is  a  frequent  symptom  of  all 
forms  of  spinal  paralysis,  and 
more  rarely  of  cerebral  paralysis. 

Symptoms. — The  patient  is 
unable  to  flex  the  leg  at  the 
hip-joint,  or  to  raise  the  body 
from  the  recumbent  position, 
and  the  muscles  are  often  atro- 
phied. He  cannot  extend  the 
leg,  and,  when  sitting,  cannot 
move  the  leg  forwards.  Stand- 
ing and  sitting  upright  are  ren- 


FlG.  111. 


Fig.  111.    Deep  Muscles  of  the  Gluteal 
Region  (after  Heath). 

1,  Hium. 

2,  Sacrum. 

3,  Posterior  sacro-iliac  ligaments. 

4,  Tuberosity  of  the  ischium. 

5,  Great  sacro-sciatic  ligament. 

6,  Lesser  sacro-sciatic  ligament. 

7,  Trochanter  major. 

8,  Gluteus  minimus. 

9,  Pyriformis. 

10,  Gemellus  superior. 

11,  Obturator  internus,  passing  out  of 

the  lesser  sacro-sciatic  foramen. 

12,  Gemellus  inferior. 

13,  Quadratus  femoris. 

14,  Adductor  magnus. 

15,  Vastus  extemus. 

16,  Biceps. 

17,  Gracilis. 

18,  Semi-tendinosus. 

The  tendon  of  the  obturator  exter- 
nus  should  appear  between  the  gemellus 
inferior  and  the  quadratus  femoris. 


650 


DISEASES   OF  THE  DORSAL  NERVES 


Fig.  112. 


dered  insecure ;  walking,  jumping,  and  running  are  rendered 
difficult  or  impossible,  and  the  difficulty  is  much  increased  when 
both  crural  nerves  are  affected. 

Disturbances   of  sensibility   are   frequently  observed,  which 
extend  over  the  lower  two-thirds  of  the  thigh,  the  region  of  the 

knee,  and  the  inner  side  of  the 

leg  and  foot. 

(b)  Paralysis  in  the  Region 
of  Distribution  of  the  Obtu- 
rator Nerve. — The  obturator 
nerve  supplies  the  adductors  of 
the  thigh,  the  gracilis,  the  ob- 
turator externus,  and,  in  part, 
the  pectineus.  Paralysis  of  this 
nerve  is  rarer  than  crural  paraly- 
sis, but  it  is  frequently  associated 
with  the  latter.  Strangulated 
obturator  hernia,  and  pressure 
of  the  head  of  the  child  or  of 
obstetric  instruments  in  diffi- 
cult deliveries,  may  cause  para- 
lysis of  the  obturator  nerve. 

Symptoms. — The  patient  is 
incapable  of  adducting  the 
thigh,  of  pressing  the  knees 
together,  or  of  crossing  one  leg. 
over  the  other.  Rotation  of  the 
thigh  outwards  is  rendered  diffi- 
cult, and  the  affected  leg  soon 
tires  in  walking.  Some  disturb- 
ances of  sensibility,  extending 
down  the  inner  side  of  the  thigh 
as  low  as  the  knee,  are.  per- 
ceptible. 

(c)  Paralysis  of  the  Muscles 
supplied  by  the  Gluteal  Nerves. 
The  gluteal  nerves  supply  the 
tensor  fasciae  and  the  gluteus 
minimus  and  medius. 


Fig.  112.  Muscles  of  the  Posterior  Femoral 
and  Gluteal  Region  (after  Heath). 

1,  Gluteus  medius. 

2,  Gluteus  maximus. 

3,  Vastus  externus  covered  in  by  fascia 

lata. 

4,  Long  head  of  biceps. 

5,  Short  head  of  biceps. 

6,  Semi-tendinosus. 

7,  Semi-membranosus. 

8,  Gracilis. 

9,  Part  of   the   inner  border  of   the 

adductor  magnus. 

10,  Edge  of  sartorius. 

11,  Popliteal  space. 

12,  Gastrocnemius ;  its  two  heads. 


AND   LUMBAR   PLEXUS.  651 

This  form  of  paralysis  is  rare,  occurring  generally  as  a  symp- 
tom of  paralysis  due  to  tumours  and  lesions  of  the  cauda  equina, 
to  fractures  of  the  sacrum  and  pelvis,  and  to  spinal  disease.  The 
most  prominent  characters  of  pseudo-hypertrophic  paralysis,  and 
sometimes  of  progressive  muscular  atrophy,  are  not  unfrequently 
due  to  paralysis  and  atrophy  of  the  gluteal  muscles. 

Symptoms. — Rotation  of  the  leg  both  inwards  and  outwards 
is  interfered  with,  and  the  power  of  abduction  is  impaired. 
Some  uncertainty  is  felt  in  standing,  the  patient  experiences 
great  difficulty  in  ascending  stairs,  and  when  the  body  is  inclined 
forwards,  it  is  difficult  to  raise  it  to  the  erect  posture.  The 
characteristic  rotation  of  the  pelvis  (§  80),  produced  by  the  con- 
traction of  the  gluteus  medius  during  locomotion,  is  not  effected, 
and  the  muscle  is  not  felt  rigid  on  the  side  of  the  active  leg,  as 
in  health,  when  the  hand  is  laid  over  the  pelvis  above  the 
trochanter.  Atrophy  of  the  muscles  is  common,  but  disturbances 
of  sensibility  are  only  present  when  other  nerves  are  coincidently 
affected. 

Treatment. — The  treatment  of  the  various  forms  of  spasm  and 
paralysis  in  the  region  of  distribution  of  the  lumbar  nerves  must 
be  conducted  on  general  principles,  and  does  not  require  to  be 
described  in  detail. 


652 


CHAPTEE   VIII. 


DISEASES   OF   THE   SACEAL  AND   COCCYGEAL   NERVES. 

The  sacral  plexus  is  formed  by  the  union  of  the  lumbo-sacral 
cord,  resulting  from  the  junction  of  part  of  the  fourth  and  the 
fifth  lumbar  nerves,  with  the  anterior  divisions  of  the  first  three 
sacral  nerves  and  part  of  the  fourth  nerve.  The  remaining 
portion  of  the  fourth  nerve  supplies  branches  to  the  viscera 
and  muscles  of  the  pelvis,  and  sends  a  connecting  filament  to 
the  fifth  nerve.  The  fifth  sacral  nerve  descends  upon  the 
coccygeus  and  turns  backwards  over  the  tip  of  the  coccyx  to 
end  in  the  integument  of  the  posterior  and  lateral  aspects  of 
the  bone. 

§  297.  Functions  of  the  Sacral  Plexus. — The  same  means  have  been 
adopted  by  anatomists  and  physiologists  to  determine  the  functions  of  the 
respective  nerves  of  the  sacral  plexus  which  have  already  been  described 
in  the  case  of  the  brachial  plexus  (§  286).  The  following  are  the  results 
obtained  by  Professors  Ferrier  and  Yeo.^ 

"  Third  Lumbar. — Flexion  of  the  thigh  and  extension  of  the  leg. 

"  Fourth  Lumbar. — Extension  of  the  thigh,  extension  of  the  leg,  and 
pointing  of  the  great  toe. 

"  Fifth  Lumbar. — Outward  rotation  of  the  thigh,  flexion  and  inward 
rotation  of  the  leg,  plantar  flexion  of  the  foot,  and  flexion  of  the  distal 
phalanges. 

"  First  Sacral. — Flexion  of  the  leg,  plantar  flexion  of  the  foot,  flexion  of 
all  the  toes  at  the  proximal  phalanges,  and  also  of  the  distant  phalanx 
of  the  hallux. 

"  Second  Sacral — Action  of  the  intrinsic  muscles  of  the  foot,  zig,  adduc- 
tion and  flexion  of  the  hallux,  with  flexion  of  the  proximal  phalanges 
and  extension  of  the  distal." 

'  Ferrier  (D.).  *'  The  localisation  of  atrophic  paralyses."  Brain,  Vol.  IV.,  1882, 
p.  224. 


DISEASES  OF  THE  SACKAL  AND  COCCYGEAL  NERVES.      653 

(A)  Sensory  Disorders  of  the  Sacral  and  Coccygeal  Nerves. 

(1)  Neuralgia  in  the  Region  of  the  Sacral  Plexus. 

§  298.  General  Characters  of  the  Disease. — Neuralgia  a£fecting 
the  sensory  branches  of  the  sacral  plexus  may  be  divided  into 
(a)  those  affecting  the  small  and  great  sciatic  nerves ;  and  {b) 
those  which  occur  in  the  neighbourhood  of  the  anus,  perinseum, 
and  external  generative  organs. 

(a)  Neuralgia  Ischiadica  {Sciatica). 

Sciatica  may  affect  the  greater  portion  of  the  posterior  surface 
of  the  thigh  and  a  part  of  the  buttock,  the  knee  cap  and  knee 
joint,  the  posterior,  anterior,  and  lateral  surfaces  of  the  leg,  and 
the  whole  foot,  with  the  exception  of  its  internal  border. 

Etiology. — Most  cases  of  sciatica  result  from  external  causes, 
although  indirect  inheritance  must  be  regarded  as  exercising  a 
considerable  influence  in  the  causation  of  the  affection.^  The 
largest  number  of  cases  occur  between  forty  and  fifty  years  of 
age,  or  during  the  time  of  commencing  bodily  degeneration. 
After  the  age  of  thirty  years  the  number  of  males  affected 
greatly  exceeds  that  of  females. 

Of  the  exciting  causes  exposure  to  cold  is  probably  the  most 
frequent.  Injuries  to  the  nerve  also  give  rise  to  sciatica,  and 
gunshot  wounds  sometimes  occasion  the  severest  and  most  in- 
tractable forms  of  the  disease.  Falls  on  the  buttock,  prolonged 
and  difficult  labour,  especially  when  the  forceps  is  used,  and 
fractures  may  likewise  be  mentioned  as  exciting  causes  of  the 
disease. 

Dr.  Anstie  regarded  violent  exertion  of  the  lower  extremities 
as  a  frequent  cause  of  sciatica,  especially  at  the  period  of 
commencing  bodily  degeneration.^  Mechanical  pressure  caused 
by  sitting  on  hard  seats,  or  by  accumulation  of  fseces  in  the 
sigmoid  flexure,  enlargements  and  displacements  of  the  uterus, 
pregnancy,  and  every  kind  of  tumour  which  presses  upon  the 
pelvic  organs  may  induce  severe  sciatica.  Haemorrhoids,  and 
conditions  inducing  congestion  of  the  various  plexuses  of  the 

'  See  Anstie  (F.  E.).  "  A  clinical  lecture  on  sciatica,  and  its  treatment."  The 
Medical  Times  and  Gazette,  Vol.  I.,  1874,  pp.  581  and  637. 

^  Anstie  (F.  E.).    Neuralgia,  and  the  diseases  that  resemble  it.    1871.    p.  48. 


654 


DISEASES   OF  THE   SACRAL 
Fig.  113. 


Fig.  113.   Sacral  and  Coccygeal  Nerves. 

VL,  IS,  IIS,  HIS,  IVS,  VS,  VIS.— Fifth  lumbar,  and  first,  second,  third,  fourth, 

fifth,  and  sixth  sacral  nerves. 
LS,  Lumbo-sacral  cord. 

c,c.  Posterior  cutaneous  nerves, 
m.  Branches  to  muscles  of  back. 

1,  Branches  to  pyriformis  muscle. 

3,  Muscular  branches  to  obturator  internus, 
3',  „  ,,  gemellus  superior. 

3",  „  ,,  gemellus  inferior. 

3",  ,,  „  quadratus  femoris. 

SGr,  Superior  gluteal  nerve. 

2,  Muscular  branches  to  gluteus  medius. 
2',  „  „  gluteus  miniirius. 

2".  ,,  „  tensor  vaginae  femoris. 


AND   COCCYGEAL  NERVES.  655 

SS,  Small  sciatic  nerve. 

12,  Muscular  branch  to  gluteus  maximus. 

I  Gr,  Inferior  gluteal  nerve  (cutaneous).  [external  labium.' 

I  P,  Inferior  pudendal  nerve,   cutaneous  to  perinaeum  and  scrotum,  or 
C",  Cutaneous  branch  to  back  of  thigh  and  upper  part  of  leg. 
P,  Pudic. 

dp,  Dorsalis  penis  sen  clitoridis. 

13,  Muscular  branch  to  transversus  perinaei. 
13',  ,,  ,,  erector  penis. 

13",         ,,  ,,  compressor  urethras. 

13'",        ,,  ,,  accelerator  urinaj. 

13"",  Branch  to  the  bulb. 

CLsp,  Anterior  superficial  perinaeal  )  to  perinseum  and  scrotum, 
psp.  Posterior  superficial  perinseal )         or  external  laDium. 
I  H,  Inferior  haemorrhoidal. 
IVS,  Fourth  sacral  nerve. 

14,  Muscular  branch  to  levator  ani. 
14',  ,,  ,,  sphincter  anL 
14",         ,,            ,,  coccygeus. 

GS,  Great  sciatic  nerve. 

hj,  Branch  to  hip-joint. 

4,  Muscular  branches  to  semi-tendinosus. 
4',  ,,  ,,  semi-membranosus. 

5,  ,,  ,,  adductor  magnus. 
5',          „             ,,  biceps. 

IP,  Internal  popliteal. 

6,  Muscular  branch  to  gastrocnemius  (inner  head). 
6',  ,,  ,,  ,,  (outer  head). 
6",         ,,            „            popliteus. 

6"',        ,,  ,,  soleus. 

PT,  Posterior  tibial  nerve. 

7,  Muscular  branch  to  tibialis  posticus. 

7',  ,,  „  flexor  longus  digitorum. 

7",  „  ,,  flexor  longus  pollicis. 

pc.  Plantar  cutaneous. 

Int.  P,  Internal  plantar  nerve. 

8,  Muscular  branch  to  abductor  pollicis.  ' 
8',          „            ,,            flexor  brevis  pollicis. 

8",         „  „  first  lumbricalis. 

S"',         ,,  ,,  second  lumbricalis. 

8  X ,       „  „  flexor  brevis  digitorum. 

t\  to  i3.  Digital  branches. 
Ext.  P,  External  plantar. 

i4  and  ^5,  Digital  branch  to  fifth  and  outer  half  of  fourth  toe. 
10',  Muscular  branch  to  flexor-accessorius  muscle. 
10",  ,,  ,,  abductor  minimi  digitL 

9,  , ,  „  flexor  minimi  digiti. 
9',            „            ,,            fourth  lumbricalis. 

DB,  Deep  branch  of  external  plantar  nerve. 
9",  ,,  „  transversalis  pedis. 

9'",         ,,  „  third  lumbricalis, 

»3  «2  »1  i  third,  second,  and  first  plantar  interossei 

P  }P  iP  i  )>  ■^     muscles. 

d4  d3  d2  c£l  -I  ^''^"^''^'   tJiird,   second,   and  first  dorsal 

'      '      '      '         "  1.     interossei  muscles. 

10,  ,,  ,,  adductor  pollicis. 

ES,  External  or  short  saphenous  to  outer  side  of  foot. 
EP,  External  popliteal. 

CP,  Communicans  peronei. 

C,  Cutaneous  to  outer  side  of  leg, 

MC,  Musculo-cutaneous  nerve. 

11,  Muscular  branch  to  peroneus  longus. 

11',  „  _  _     ,,  peroneus  brevis. 

AT,  Anterior  tibial  nerve. 

11",  Muscular  branch  to  tibialis  anticus. 

11'",  ,,  ,,  extensor  longus  digitorum. 

11"",         „  ,,  extensor  longus  polliciis. 

11 X,        „  ,,  extensor  brevis  digitorum. 

Kj,  „  ,,  knee-joint. 

at,  Articular  branch  to  tarsus. 


656 


DISEASES  OF  THE  SACRAL 


Fig.  114. 


pelvis,  such  as  obstruction  of  the  portal  circulation  and  habitual 
constipation,  are  not  unfrequent  exciting  causes  of  the  disease. 
It  is  important  to  remember  that  sciatica  may  be  caused  by 

rheumatism  or  syphilis/  while 
Fournier^  has  directed  attention 
to  the  frequent  connection  be- 
tween it  and  gonorrhoea. 

Symptoms. — An  attack  of 
sciatica  is  generally  preceded 
by  premonitory  symptoms,  such 
as  a  sensation  of  fluid  trickling 
over  the  skin,  or  a  feeling  of 
cold  or  heat,  formication,  and  a 
sense  of  stiffness  and  dragging. 
After  a  time  the  symptoms  of 
true  neuralgia  make  their  ap- 
pearance. Lightning-like  pains 
are  felt,  which  gradually  in- 
crease in  intensity  until  a  vio- 
lent paroxysm  is  established. 
The  pain  proceeds  from  one  or 
more  fixed  points,  and  usually 
radiates  in  a  descending  direc- 
tion, although  it  occasionally 
radiates  in  an  ascending,  or  in 
several  directions.  It  is  gene- 
rally seated  in  the  skin,  but 
may  be  felt  in  and  between  the 
muscles,  or  even  in  the  bones. 
There  is,  as  a  rule,  an  exacerba- 
tion of  the  pain  at  night,  but  it 
does  not  completely  disappear 
during  the  day,  and  then  there 
is  a  sense  of  tension  and  un- 
easiness in  the  affected   limb. 


Fig.  114.  Second  Stage  of  Dissection  of 
Sole  of  Foot  (from  Hirschfeld  and 
Leveille). 

1,  Internal  annular  ligament. 

2,  Flexor  brevis  digitorum  (cut). 

3,  External  plantar  nerve. 

4,  External  plantar  artery. 

5,  Internal  plantar  nerve. 

6,  Abductor  minimi  digiti. 

7,  Internal  plantar  artery. 

8,  Accessorius  muscle. 

9,  Abductor  pollicis. 

10,  Flexor  longus  digitorum, 

11,  Flexor  longus  pollicis. 

12,  Flexor  brevis  minimi  digiti. 

13,  Digital  branches  of  internal  plantar 

nerve. 

14,  Digital  branches  of  external  plantar 

nerve. 

15,  Flexor  brevis  pollicis. 

16,  One  of  the  lumbricalea. 


1  Buzzard.  The  Lancet.  Vol.  I., 
1879,  p.  2S9. 

^  Fournier.  L'XJnion  M^dicale,  Nov., 
1868;  and  The  Medical  Times  and 
Gazette,  VoL  II.,  1868,  p.  647. 


AND   COCCYGEAL  NERVES.  657 

Occasionally,  however,  the  pain  is  easier  at  night,  and  worse 
during  the  day. 

Every  movement  of  the  limb  generally  augments  the  pain, 
and  such  trifling  actions  as  are  involved  in  turning  in  bed, 
coughing,  sneezing,  and  straining  at  stool,  or  even  simple  contact 
of  the  bed-clothes,  may  bring  on  a  paroxysm ;  hence  the  limb  is 
maintained  in  a  fixed  position,  with  all  the  joints  slightly  bent. 
Patients  are,  however,  occasionally  met  with  who  find  relief  in 
walking  about,  and  who  cannot  remain  in  bed. 

The  area  in  which  the  pain  is  felt  varies  considerably  in 
different  cases.  The  pain  is  most  commonly  felt  in  the  pos- 
terior surface  of  the  thigh,  commencing  in  the  neighbourhood  of 
the  sciatic  foramen,  and  extending  to  the  popliteal  space  and 
calf  of  the  leg.  The  next  part  which  is  most  frequently  affected 
is  the  peroneal  region,  including  the  anterior  and  external  surface 
of  the  leg,  and  the  dorsum  of  the  foot.  The  region  of  distribution 
of  the  tibial  nerve  is  more  rarely  affected,  though  cases  have 
been  observed  in  which  the  pain  is  confined  to  the  sole  of  the 
foot  (neuralgia  plantaris).  One  variety  of  the  latter  is  so  im- 
portant as  to  deserve  separate  description. 

Sometimes  the  whole  area  of  distribution  of  the  nerve  is 
affected,  and  the  violence  of  the  pain  may  shift  from  one  region 
to  another.  Violent  pains  in  the  sacrum  and  loins  are  usually 
felt  along  with  sciatica,  from  implication  of  the  posterior 
branches  of  the  sacral  nerves. 

The  pain  of  sciatica  may  radiate  to  other  nerve  territories. 
It  may  shoot  into  the  lumbar  nerves  and  their  branches,  into 
the  sciatic  nerve  of  the  opposite  side,  or  into  more  remote 
nerve  regions.  Partial  ansesthesia  of  portions  of  the  skin  of  the 
affected  extremity  is  frequently  observed,  and  hypersesthesia  of 
circumscribed  areas  is  not  uncommon. 

Painful  points  are  rarely  absent,  although  it  is  somewhat  difficult  to 
detect  them  in  some  cases.  The  places  which  are  apt  to  be  specially  tender 
are  ;  (1)  A  series  of  points  representing  the .  cutaneous  emergence  of  the 
posterior  branches,  reaching  from  the  lower  end  of  the  sacrum  up  to  the 
crista  ilii ;  (2)  A  point  opposite  the  emergence  of  the  great  and  small 
sciatic  nerves  from  the  pelvis  ;  (3)  A  point  opposite  the  cutaneous  emer- 
gence of  the  ascending  branches  of  the  small  sciatic,  which  run  up  towards 
the  crista  ilii ;  (4)  Several  points  at  the  posterior  aspect  of  the  thigh 
corresponding  to  the  emergence  of  the  cutaneous  nerves;  (5)  A  fibular 
VOL.  L  QQ 


658  DISEASES  OF  THE   SACRAL 

point  at  the  head  of  the  fibula  corresponding  to  the  division  of  the  external 
popHteal  •,{'6)  An  external  malleolar  point  behind  the  ankle ;  (7)  J  w,  intemaC 
malleolar  point.  The  sacral  plexus  itself  can  be  reached  by  examination 
per  anum  or  per  vaginum,  and  is  frequently  found  painful  on  pressure. 

Motor  disturbances  are  more  frequent  in  sciatica  tlian  in  any 
other  form  of  neuralgia.  Complete  paralysis  is  rare,  but  in  a 
large  proportion  of  cases  of  long  standing  there  is  a  consider- 
able diminution  of  motor  power,  and  consequently  the  gait  is 
limping.  The  limp  may  occasionally  be  caused  by  the  restriction 
of  the  movements  of  the  leg  on  account  of  the  pain,  but  as  a 
rule  it  is  the  result  of  aln  enfeebled  condition  of  the  muscles. 

Convulsive  movements  of  the  legs  are  met  with  in  a  con- 
siderable proportion  of  cases.  Cramps  of  particular  muscles 
may  occur,  consisting  sometimes  of  slight  fibrillary  contractions, 
and  at  other  times  of  strong  convulsions.  The  cramps  generally 
supervene  at  night  when  the  patient  is  falling  asleep. 

The  most  usual  vaso-motor  and  trophic  disturbances  are 
pallor  and  coldness,  or  redness  and  heat  of  the  surface,  increased 
secretion  of  sweat,  atrophy,^  or  occasionally  hypertrophy  of  some 
of  the  muscles.  In  a  case  of  sciatica  which  I  saw  in  consultation 
with  my  friend  Mr.  Stocks,  the  relative  coldness  of  the  affected 
limb  was  very  well  marked. 

The  electric  sensibility  of  the  skin  to  the  farad ic  currejit  is 
slightly  diminished  when  anaesthesia  is  present. 

Course,  Duration,  and  Terminations. — Sciatica,  as  a  rule, 
lasts  several  weeks  even  in  favourable  cases.  Occasionally 
recovery  takes  place  in  a  few  days,  but  more  frequently  the 
affection  persists  for  months.  The  attacks  supervene  irregularly; 
each  commences  gradually,  rises  to  a  certain  intensity,  at  which  it 
remains  with  some  variations  for  a  longer  or  shorter  time,  and 
then  gradually  subsides.  Improvement  is  usually  very  gradual, 
and  even  when  the  pain  has  disappeared  the  leg  remains  weak, 
stiff,  and  easily  tired,  and  the  patient  is  liable  to  a  relapse 
on  slight  provocation.  In  cases  unassociated  with  organic  disease 
the  usual  duration  of  the  pain  varies  from  two  to  eight  weeks, 
but  when  it  is  the  result  of  organic  changes  it  may  last  during 
the  rest  of  life. 

^  Landouzy.  "  De  la  sciatique  et  de  I'atropliie  musculaire  qui  peut  la  com- 
pliquer."    Arch,  g^n^r.  de  m6d.,  Vie  ge'rie,  Tome  XXV.,  1875,  pp.  303,  424,  et  562. 


AND   COCCYGEAL  NERVES. 

Fig.  115. 

i 


659 


r  pp  ^ 


Fig.  115  (after  Flower).    Cutaneous  Nerves  of  the  Lower  Exiremity.    Anterior  View 
of  Lower  Extremity. 
Lumbar  Plexus. 

IH,  Ilio-hypogastric  nerve. 

II,  Ilio-inguinal. 

IIL,  Second  lumbar  nerve, 

GO,  Genito-crural. 

EC,  External  cutaneous. 

MC,  Middle  cutaneous. 

10,  Internal  cutaneous. 

IS,  Internal  saphenous. 

PP,  Plexus  patellae. 
Sacral  Plexus. 

DP,  Dorsalis  penis  of  pudic. 

IP,  Inferior  hemorrhoidal  of  pudic. 

P,  Superficial  perinseal  of  pudic  and  inferior  pudendal  of  small  sciatic. 

IG,  Inferior  gluteal  of  small  sciatic. 

SS,  Small  sciatic. 

EP,  Branches  from  external  popliteal. 

ES,  External  saphenous. 

MCS,  Musculo-cutaneous. 

AT,  Branches  of  anterior  tibial. 

PT,  Branch  of  posterior  tibial. 


660  DISEASES   OF  THE   SACRAL 

Morbid  Anatomy. — ^Various  changes  have  been  found  in  the 
nerve  itself  in  cases  of  intractable  neuralgia.  The  changes  most 
commonly  described  are  congestion,  oedema,  neuritis,  exudation, 
deposit  of  tubercle,  ossification  of  the  neurilemma,  tumours,  and 
neuromata. 

Diagnosis. — The  diagnosis  of  sciatica  is  surrounded  by  con- 
siderable difficulties,  especially  in  women,  in  fat  persons,  and  in 
ignorant  people,  who  cannot  give  a  good  description  of  their 
subjective  sensations.  It  may  be  mistaken  for  myalgia  of  the 
thigh  or  leg,  but  the  pain  in  the  latter  affection  has  a  diffused 
localisation,  so  that  the  patient  indicates  its  seat  with  his  whole 
hand,  whilst  in  neuralgia  he  points  to  it  with  his  finger.  The 
pain  in  myalgia  is  also  increased  by  the  performance  of  definite 
movements. 

Sciatica  may  also  be  very  readily  confounded  with  hip-joint 
disease,  and  in  slowly-developing  cases  of  the  latter  affection, 
without  fever  or  deformity,  an  error  in  diagnosis  can  only  be 
avoided  with  the  exercise  of  the  greatest  care.  It  is  still  more 
difficult  to  distinguish  between  hysterical  coxalgia  and  sciatica. 
The  absence  or  presence  of  pain  when  the  head  of  the  femur  is 
pressed  against  the  acetabulum,  the  age  and  the  state  of  the 
general  health,  the  elongation  or  shortening  of  the  leg,  the  shape 
of  the  lower  part  of  the  back,  the  situation  of  the  painful  points, 
the  paroxysmal  character  of  the  pain  and  its  mode  of  distribution, 
the  presence  or  absence  of  fever  and  inflammation,  and  the  mode 
of  carrying  the  leg,  must  all  be  taken  into  account  in  forming  a 
diagnosis.  Inflammation  of  the  psoas  muscle  can  be  readily  dis- 
tinguished from  sciatica. 

It  is  important  to  determine  whether  the  disease  be  seated  in 
the  course  of  the  nerves,  the  plexus,  the  roots,  or  in  the  central 
parts  of  the  nervous  system.  The  nerve  is  affected  in  its  course 
when  the  pain  is  localised  in  particular  branches,  and  when  the 
concomitant  motor  and  vaso-motor  disturbances  are  well  marked. 
The  plexus  is  probably  affected  when  the  pain  has  a  wide  dis- 
tribution, and  when  tenderness  is  produced  on  pressure  being 
made  from  the  rectum.  When  the  pain  extends  to  the  posterior 
branches  of  the  sacral  plexus,  is  localised  in  the  bones,  and  has 
a  well-marked  lancinating  character,  it  is  more  likely  to  be 
seated  in  the  roots  or  centres,     In  order  to  distinguish  whether 


AND   COCCYGEAL  NEEVES.  661 

the  roots  or  centres  are  affected,  attention  must  be  paid  to  the 
nature  of  the  concomitant  symptoms.  The  determination  of  the 
cause  of  the  sciatica  is  of  the  greatest  importance  in  treatment. 

Prognosis. — The  prognosis  is  not  so  favourable  in  sciatica  as 
in  crural  neuralgia,  but  in  recent  idiopathic  or  rheumatic  cases 
the  prognosis  is  always  favourable.  Slowly-developing  cases, 
associated  with  angesthesia,  paralysis,  and  atrophy,  are  always 
obstinate,  and  when  the  neuralgia  is  only  a  symptom  of  some 
incurable  disease  the  prognosis  is  very  grave.  Long  duration 
and  old  age  add  to  the  gravity  of  the  prognosis.  The  sleepless- 
ness caused  by  the  constant  pain  may  impair  the  appetite  and 
lead  to  exhaustion,  but  sciatica  of  itself  is  never  fatal. 

§  299.  Neuralgia  Plantaris. — Although  the  tibial  nerve  is 
rarely  affected,  yet  one  variety  of  neuralgia  in  the  area  of  distribu- 
tion of  this  nerve  is  so  important  as  to  deserve  special  mention. 
Dr.  S.  Weir  Mitchell,  who  has  done  so  much  to  advance  our  know- 
ledge of  nervous  diseases,  was  the  first  to  give  an  accurate 
description  of  this  affection  under  the  title  of  "On  a  rare  vaso- 
motor neurosis  of  the  extremities."^  But  inasmuch  as  the  vaso- 
motor disturbances  are  preceded  and  accompanied  throughout 
by  severe  paroxysms  of  pain,  I  see  no  reason  why  the  affection 
should  not  be  regarded  as  one  of  plantar  neuralgia,  or  perhaps 
as  a  neuritis  of  the  plantar  nerves. 

The  disease  occurs  nearly  always  in  the  male  sex,  although  I  have  met 
with  one  well-marked  example  of  it  in  a  woman  ;  it  comes  on  after 
some  constitutional  disease  as  a  low  fever,  or  after  prolonged  exertion,  and 
in  a  case  under  my  care  the  affection  was  the  sequel  of  an  attack  of  gonor- 
rhoeal  rheumatism.  It  is,  indeed,  probable  that  the  cases  of  obstinate  pain 
in  the  sole  of  the  foot  described  by  Dr.  Elliotson^  as  following  gonorrhoeal 
rheumatism  belong  to  this  category.  The  pain  usually  begins  in  the  ball 
of  the  great  toe,  or  in  the  heel,  and  often  extends  over  a  great  part  of  the 
sole,  and  may  reach  the  dorsum  of  the  foot  and  leg.  It  is  generally  limited 
to  circumscribed  areas  of  one  or  both  soles,  and  does  not  extend  beyond. 
It  is  felt  at  first  towards  night,  and  is  relieved  by  the  night's  rest ;  it  is 
increased  by  walking,  the  erect  posture,  or  even  by  allowing  the  foot  to  hang 
down.  The  pain  is  felt  at  fii'st  as  a  deep  aching,  but  after  a  time  it  becomes 
of  a  burning  character,  and  is  then  aggravated  by  warmth,  and  reUeved  by 

'  Mitchell  S.  Weir).  The  American  Journal  of  the  Medical  Sciences.  Vol. 
LXXVI.,  July,  1878,  p.  17. 

^  See  Elliotson.    The  Medical  Times  and  Gazette.     Vol.  I.,  1860,  p.  643. 


662 


DISEASES   OF   THE   SACRAL 


cold  and  the  recumbent  posture.  The  most  characteristic  symptom  of  the 
affection,  however,  is  a  flushing  of  the  painful  area  which  comes  on  with 
exertion,  or  when  the  feet  are  allowed  to  hang  down.  "The  foot,"  says  Dr. 
Mitchell,  "  gets  redder  and  redder,  the  veins  stand  out  in  a  few  minutes  as 

if  a  ligature  had  been  tied  around 
Fig.  116.  f]^Q  hmb,    and   the   arteries   throb 

,  violently  for  a  time,  until  at  length 

the  extremity  becomes  of  a  dark 
piurplish  tint.  In  the  worst  cases, 
when  the  patient  is  at  rest,  the 
limbs  are  cold,  and  even  pale."  In 
aggravated  cases  the  pain  is  so  severe 
as  to  render  walking  all  but  impos- 
sible, and  when  persisted  in  intense 
redness  and  swelling  are  occasioned ; 
the  patient  sleeps  with  uncovered 
feet,  and  in  the  worst  cases  crawls 
on  his  hands  and  knees,  or  is  carried 
about  in  order  to  avoid  placing  his 
feet  on  the  ground.  The  disease  is 
at  times  progressive,  and  in  the  later 
stages  it  is  associated  with  evidences 
of  spinal  disease,  such  as  girdle 
pains,  partial  paralysis,  and  atrophy  of  some  of  the  muscles  of  the  leg.  In 
an  interesting  case  recorded  by  Dr.  Stm-ge^  there  was  considerable  diminu- 
tion of  the  faradic  contractility  in  all  the  muscles  of  the  limb  most  affected. 
In  one  of  the  cases  observed  by  Dr.  Mitchell  the  disease,  which  had  at  first 
been  confined  to  the  feet,  extended  at  a  later  stage  to  the  hands  also.  In 
the  case  observed  by  me  there  was  a  tender  spot  over  the  centre  of  the  heel, 
the  whole  course  of  the  external  plantar  nerve  was  very  tender  to  pressure, 
and  painful  points  were  fovmd  between  the  heads  of  the  metatarsal  bones 
at  the  bifurcation  of  the  branches  of  the  plantar  nerves  for  the  digits.  The 
feet  were  generally  bathed  in  a  sour-smelling  sweat,  and  the  skin  of  the  sole 
had  a  sodden  appearance,  becoming  somewhat  glazed  dm-ing  the  paroxysm 
of  pain  and  redness.  These  cases  are  extremely  intractable  to  treatment. 
The  accompanying  diagram,  borrowed  from  Dr.  MitcheU,  is  almost  an 
exact  representation  of  the  distribution  of  the  redness  in  the  case  under 
my  care. 

The  disease  which  is  most  liable  to  be  mistaken  for  plantar  nevu-algia  is 
Podynia — an  affection  peculiar  to  tailors — described  by  Dr.  Gross.  This 
affection  consists  of  burning  pain  in  some  i^art  of  the  sole,  but  there  is  no 
redness.  It  appears  to  depend  upon  subacute  inflammation  of  the  perios- 
teum. A  painful  spot  on  the  heel  may  be  observed  after  syphihs,  but 
careful  examination  will  reveal  a  node  on  the  os  calcis. 


»  Sturge.    The  Lancet.    Vol.  I.,  1879,  p.  596. 


AND   COCCYGEAL  NERVES.  663 

(6)   JS^euralgia  of  the  Coccygeal  Nerves  (Goccygodynia). 

The  chief  symptom  of  coccygodynia  consists  of  pain  in  the 
region  of  the  coccyx  when  the  patient  sits  or  walks,  and  often  also 
during  micturition  and  defecation,  especially  if  there  be  much 
straining.  Pressure  on  the  coccyx  with  the  finger  induces  pain. 
The  affection  is  generally  observed  in  women,  in  whom  it  occurs 
in  conseqaence  of  injury  .to  the  coccyx  from  a  fall,  during  labour, 
or  from  exposure  to  cold,  and  it  may  originate  spontaneously.  It 
is  probably  caused  by  irritation  of  the  bone  itself  or  of  its  fibrous 
investment,  but  occasionally  it  may  be  neuralgic,  and  is  always 
of  long  duration. 

Treatment. — The  first  indication  of  treatment  is  to  remove 
the  cause  of  the  disease.  When  sciatica  arises  in  a  patient 
suffering  from  hsemorrhoids,  venous  stasis,  and  constipation,  pur- 
gatives and  saline  waters,  such  as  those  of  Kissingen  and 
Marienbad,  give  good  results.  An  enema  containing  turpentine 
has  been  strongly  recommended  in  some  of  these  cases.  When 
the  neuralgia  results  from  external  disease,  it  may  be  necessary 
to  resort  to  operative  procedure,  such  as  removal  of  tumours, 
coaptation  of  fractures,  resection  of  cicatrices,  and  removal  of 
foreign  bodies ;  if  there  be  traumatic  neuritis,  a  pressure 
bandage  may  be  applied  to  the  whole  extremity.  When  the 
disease  is  of  central  origin,  the  appropriate  treatment  for  the 
particular  lesion  must  be  adopted.  Recent  rheumatic  cases, 
which  are  by  far  the  most  common,  should  be  treated  by 
diaphoresis,  the  milder  counter-irritants,  the  vapour  or  Turkish 
bath,  and  absolute  rest ;  in  chronic  cases  iodide  of  potassium 
and  the  indifferent  thermal  baths  prove  serviceable. 

Blisters  are  one  of  the  most  useful  agents  in  the  treatment  of 
sciatica,  and  they  are  best  applied  in  the  form  of  flying  blisters 
over  the  course  of  the  painful  nerve,  Anstie  recommended  the 
application  of  the  blister  over  the  sacrum,  so  as  to  be  directly 
opposite  the  posterior  roots  of  the  nerve,  but  it  has  been  found 
much  more  generally  useful  in  practice  to  apply  the  blister  over 
the  course  of  the  painful  nerve. 

The  actual  cautery^  is  an  excellent  remedy  in  the  more  serious 
cases,  and  the  best  mode  of  using  it  is  to  cauterise  the  skin 

'  Peter.     The  Lancet.    Vol.  I.,  1878,  p.  291. 


664  DISEASES  OF  THE  SACRAL 

superficially  in  transverse  lines  over  the  affected  nerve.  In  two 
severe  cases  of  sciatica  which  resisted  the  ordinary  mild  treat- 
ment I  injected  seven  minims  of  a  strong  solution  of  nitrate  of 
silver^  (grs.  x  to  the  3j)  subcutaneously.  This  method  produced 
severe  pain,  and  in  one  of  the  cases — an  anaemic  woman — it  was 
followed  by  what  appeared  from  the  description  to  have  been 
some  kind  of  convulsion.  In  both  instances  the  neuralgic  pain 
disappeared  in  a  few  days,  but  I  woiild  certainly  not  advise 
this  treatment  except  in  very  obstinate  cases,  and  in  moderately 
robust  individuals. 

Narcotics  cannot  be  dispensed  with  in  cases  of  even  ordinary 
severity,  and  the  subcutaneous  injection  of  morphia^  over  one  or 
other  of  the  painful  points  is  the  most  generally  useful  method 
of  administration.  A  small  blister  may  be  applied  over  the 
course  of  the  painful  nerve,  and  after  the  cuticle  has  been 
removed  the  surface  should  be  dusted  with  morphia  finely 
powdered,  from  one-sixth  to  one-third  of  a  grain  being  applied 
every  three  or  four  hours.  Atropine  may  be  tried  if  morphia 
fail.  Trousseau  recommended  an  issue  on  the  buttock  to  which 
two  or  three  pilules  are  applied  daily,  each  containing  three- 
quarters  of  a  grain  of  extract  of  opium  and  the  same  quantity 
of  belladonna,  made  up  with  gum  tragacanth.  Anodyne  lini- 
ments and  embrocations,  and  narcotic  clysters  or  suppositories 
afford  valuable  aid  in  the  treatment  of  the  disease. 

Electricity  gives  good  results  in  many  cases.  The  faradic  is 
not  so  generally  useful  as  the  constant  current.  The  former 
may  be  applied  in  the  form  of  the  electric  brush,  or  with  moist 
electrodes.  The  constant  current,  however,  is  much  more 
generally  useful,  and  it  is  equally  successful  in  recent  and  in 
chronic  cases  of  sciatica  which  do  not  depend  upon  incurable 
organic  disease.  The  descending  current  with  stabile  electrodes 
is  the  most  effectual  method  of  applying  it.  The  anode  should 
be  placed  over  the  sciatic  foramen  or  upon  the  sacrum,  and  the 
cathode  upon  the  specially  painful  parts.  Remak's  plan  may 
also  be  adopted.     According  to  this  method  separate  portions 


•  See  Blosart.  "  Du  traitement  de  la  sciatique  chronique  par  les  injections  de 
nitrate  d'argent."    These  de  Paris,  1872. 

^  See  Lawson  (H.).  The  Medical  Times  and  Gazette.  Vol.  II.,  1869,  pp.  654 
and  680. 


AND  COCCYGEAL  NERVES.  665 

of  the  nerve,  from  six  to  eight  inches  in  length,  are'  successively 
brought  under  the  influence  of  the  current,  beginning  at  the 
sacrum  and  passing  down  to  the  feet. 

Another  method  employed  by  Remak,  under  the  name  of 
circular  current,  consists  in  the  stabile  application  of  the  anode 
upon  the  trunk  of  the  nerve  and  upon  the  painful  points. 
This  method  requires  strong  currents  to  be  used,  with  broad 
electrodes,  so  that  the  current  may  pass  deeply.  In  severe 
cases,  Benedict  has  recommended  that  one  electrode  should  be 
introduced  into  the  rectum  and  the  others  placed  on  the 
sacrum,  so  that  the  current  should  be  applied  as  directly  as 
possible  to  the  seat  of  the  disease.  Ciniselli  recommended  a 
single  galvanic  element — one  zinc  and  one  copper-plate  con- 
nected by  a  wire — to  be  applied  to  the  affected  limb.  Such 
plates  may  be  adapted  to  any  part  of  the  skin,  and  may  be 
worn  for  hours  or  for  days  together,  and  are  said  to  give  good 
results. 

I  have  obtained  excellent  results  in  several  cases  of  chronic 
and  obstinate  sciatica,  by  passing  a  feeble  galvanic  current 
through  the  nerve  by  means  of  acupuncture,  the  positive  pole, 
as  the  least  painful,  being  applied  to  the  ends  of  the  needles. 

Various  specific  remedies  have  been  from  time  to  time  recom- 
mended. Rectified  oil  of  turpentine  has  been  for  a  long  time 
employed  as  a  remedy.  It  is  best  taken  in  the  form  of  gelatine 
capsules,  each  of  which  contains  about  fifteen  grains,  and  three 
to  twelve  may  be  taken  daily  at  meal  times.  Copaiba  has  been 
found  successful  in  the  hands  of  March,^  of  Rochdale.  Quinine 
has  not  been  found  very  useful  in  sciatica.  Iodide  of  potassium, 
either  alone  or  in  combination  with  guaiacum,  is  useful  sometimes, 
more  especially  in  rheumatic  cases,  and  if  there  be  a  syphilitic 
taint  it  should  be  given  in  large  doses. 

Hot  fomentations  are  frequently  beneficial,  or  poultices  may 
be  used  if  preferred.  The  indifferent  thermal  and  mud  baths 
have  for  a  long  time  enjoyed  great  repute  in  the  treatment  of 
sciatica,  and  probably  the  greatest  benefit  is  obtained  by  those 
means  in  chronic  rt  -'natic  cases.  The  most  noted  watering 
places  for   the  cure  of  bciatica  are  Teplitz,  Gastein,  Wildbad, 

»  March.    The  Medical  Times  and  Gazette..   Vol.  I.,  1881,  p.  237. 


666  DISEASES   OF  THE  SACRAL 

Wiesbaden,  and  Baden-Baden,       The  cold-water  treatment  and 
sea-water  baths  have  also  been  found  serviceable. 

In  severe  and  desperate  cases,  and  in  these  only,  surgical 
operations  are  justifiable.  In  a  case  of  severe  sciatica,  in  which 
obscure  fluctuation  was  felt  over  the  nerve,  Fayrer^  introduced  a 
sharp-pointed  bistoury,  and  a  considerable  quantity  of  serum 
escaped ;  the  patient  was  almost  immediately  and  permanently 
relieved  of  his  pain.  Kesections  of  the  smaller  sensory  branches 
may  be  undertaken  without  fear ;  but  it  should  be  remem- 
bered that  the  paralysis  which  is  produced  by  resection  of  a 
portion  of  the  sciatic  nerve,  or  of  either  of  its  two  terminal 
branches,  is  generally  incurable.  Stretching  of  the  sciatic  nerve, 
according  to  the  plan  of  Nussbaum,  is  a  much  more  promising 
operation,  since  it  not  only  relieves  the  pain,  but  voluntary 
control  over  the  movements  of  the  limbs  remains  unaffected. 
My  colleague,  Mr.  Heath,  cured  an  obstinate  case  of  sciatica  by 
stretching  the  nerve,  and  similar  cases  are  reported  by  Mac- 
farlane,^  Hichard,^  Bramwell,*  and  others,  while  Lange^  obtained 
relief  in  one  case  by  forced  flexion  of  the  thigh,  thus  stretching 
the  nerve  without  operation. 

Best  in  the  recumbent  position  should  always  be  insisted 
upon  in  the  treatment  of  sciatica.  Attention  should  also  be  paid 
to  the  regulation  of  the  diet  of  the  patient,  to  the  condition 
of  the  digestive  canal  and  to  the  state  of  the  health  generally. 
The  form  of  plantar  neuralgia  described  by  Dr.  Mitchell  has 
hitherto  proved  intractable  to  every  kind  of  treatment.  The 
posterior  tibial  nerve  was  stretched  in  one  of  my  patients  by  my 
colleague,  Mr,  Southam,  but  the  relief,  immediately  obtained, 
was  not  lasting. 

In  coccygodynia  the  usual  remedies  must  be  adopted,  but  in 
many  cases  operative  proceedings  are  necessary.  The  usual 
operations  are  extirpation  of  the  coccyx,  or,  better  still,  sepa- 
rating the  bone  by  subcutaneous  section  with  a  tenotomy  knife 
from  all  nerves  connected  with  it.  The  latter  operation  has 
proved  successful  in  several  instances. 

'  Fayrer.     The  Medical  Times  and  Gazette.     Vol.  I.,  1868,  p.  8. 

^  Macfarlane.     The  Lancet.    Vol.  II.,  1878,  p.  6. 

^  Eichard.     The  Lancet.    Vol.  I.,  1880,  p.  587. 

*  Bramwell  (J.  P.).     The  British  MedicalJournal.     Vol.  I.,  1880,  p.  920. 

*  See  Lange.     The  British  Medical  Journal.    Vol.  I.,  1881,  p.  352. 


AND  COCCYGEAL   NERVES.  667 

(B)  Motor  Disorders  of  the  Sciatic  Nerve. 
(1)  Spasm  op  the  Muscles  supplied  by  the  Sciatic  Nerve. 

§  300.  (a)  Spasm  of  the  flexors  of  the  leg  (biceps  femoris,  semi- 
tendinosus,  and  semi-membranosus)  occurs  in  the  form  of  tonic 
contraction  in  hysterical  patients,  in  diseases  of  the  spinal  cord, 
and  in  disease  of  the  knee-joint.  The  leg  is  kept  strongly  flexed 
upon  the  thigh,  and  the  contraction  is  sometimes  carried  so  far 
that  the  heel  is  brought  into  contact  with  the  buttock. 

(6)  Spasm  of  the  anterior  muscles  of  the  leg,  or  those  supplied 
by  the  peroneal  nerve,  is  of  rare  occurrence.  Weir  Mitchell  has 
described  a  peculiar  and  painful  contracture  of  the  tibialis 
anticus,  peroneus  longus,  and  gastrocnemius,  which  occurs  in 
young  people  after  long  standing,  and  leads  to  deformity  of  the 
feet.  Duchenne^  has  shown  that  spasm  of  the  peroneus  longus 
has  a  great  influence  in  producing  certain  forms  of  club-foot. 
He  has  also  drawn  attention  to  the  fact  that  the  spasms  are  of 
two  kinds  :  the  first  consisting  of  persistent  contracture  of  the 
muscle ;  the  second,  of  functional  spasm,  which  only  occurs 
when  the  leg  is  brought  into  use.  The  latter  form  is  particularly 
liable  to  occur  in  congenital  spasmodic  affections. 

(c)  Spasm  of  the  muscles  of  the  calf,  or  of  the  muscles  supplied 
by  the  tibial  nerve,  is  frequent.  The  well-known  "cramps,"  which 
occur  in  the  calf  from  contraction  of  the  gastrocnemius,  belong  to 
this  variety.  Contracture  of  the  sural  muscles  produces  talipes 
equinus,  the  heel  being  strongly  elevated,  and  the  point  of  the 
foot  depressed.  Cramps  in  the  calf  are  observed  in  sciatica,  and 
in  hypersesthesia  of  the  knee-joint. 

(d)  Diffused  spasm  of  the  whole  inferior  extremity,  or  of  both 
extrerfiities  together,  occurs  occasionally  in  hysteria.  Sometimes 
spasm  of  the  leg  may  occur  as  a  motor  aura  in  epilepsy,  and 
tonic  and  clonic  spasms  of  the  lower  extremities  are  frequently 
met  with  in  diseases  of  the  spinal  cord. 

Treatment. — The  treatment  must  first  be  directed  to  remove 
all  the  exciting  causes  of  the  disease.  The  direct  treatment 
consists  of  the  faradic  and  galvanic  currents  applied  in  the  usual 

^  Duchenne.  "  Eecherches  Electro-physiologiques  et  pathologiques  sur  les 
muscles  qui  meuvent  du  pied."  Arch,  gener.  de  Med.,  3®  Serie,  Tome  VII.,  1856, 
p.  678 ;  et  Tome  VIII.,  1856,  pp.  47  et  671 ;  and  L'Electrisation  localise'e,  3e  Edit., 
1872,  p.  1008. 


668  DISEASES   OF  THE   SACRAL 

way,  nervine  tonics,  and  antispasmodics,  along  with  tenotomy 
and  ortbopoedic  measures,  according  to  the  nature  of  the  case. 

(2)  Paralysis  of  the  Muscles  supplied  by  the  Sciatic  Nerve. 

§  301.  Etiology. — From  the  exposed  position  of  the  nerve  it  is 
liable  to  injuries  of  various  kinds,  sucb  as  laceration,  section, 
mechanical  pressure  from  the  growth  of  tumours,  fractures  of 
the  vertebral  column,  tumours  of  the  cauda  equina,  tumours 
and  abscesses^  in  the  pelvis,  compression  by  the  gravid  uterus, 
and  injury  to  one  of  the  cords  of  the  sacral  plexus  during  the 
extraction  of  the  child  by  the  forceps,^ 

Rheumatic  paralysis  of  the  sciatic  nerve,  the  result  of  a  chill, 
is  much  less  frequent.  Paralyses  from  neuritis  are  more  frequent, 
and  a  certain  amount  of  paralysis  is  frequently  left  after  severe 
sciatica,  and  in  these  cases  it  is  probable  that  the  neuralgia  was 
the  result  of  neuritis.  Paralysis  of  the  sciatic  nerve  may  also 
occur  after  acute  disease,^  and  as  a  symptom  of  hysteria.  This 
nerve  is  alway  implicated  in  the  various  forms  of  spinal  and  in 
many  cases  of  cerebral  paralysis.  It  is  also  involved  in  pseudo- 
hypertrophic paralysis,  but  is  seldom  affected  in  progressive 
muscular  atrophy. 

Symptoms. — The  paralysis  may  affect  the  nerve  as  a  whole,  or 
either  of  its  two  branches,  the  peroneal  and  tibial  nerves,  or  it 
may  be  limited  to  branches  supplying  particular  muscles. 

(a)  If  the  musculo-cutaneous  nerve  be  affected,  the  foot 
cannot  be  flexed  or  abducted,  and  can  only  be  incompletely 
adducted.  It  hangs  down  in  a  flaccid  condition  with  the  toes 
depressed,  so  that  walking  is  seriously  interfered  with,  inasmuch 
as  the  depressed  toes  are  apt  to  trip  the  patient  at  every  slight 
inequality  of  the  ground.  The  necessary  elevation  is  given  to 
the  passive  foot  in  walking  by  flexion  at  the  hip-joint,  so  that  the 
point  is  the  last  part  of  the  foot  to  be  raised  from  the  ground,  and 
on  planting  it  down,  the  outer  border  of  the  foot  and  the  toes 
touch  the  ground  first.  This  mode  of  progression  is  frequently 
observed  in  cases  of  infantile  paralysis,  and  the  gait  is  very 

1  Adams.     The  Lancet.     Vol.  11. ,  1880,  p.  669. 
^  Roberts  (D.  Lloyd).     The  Lancet.     Vol.  IL,  1881,  p.  54. 
'  Nothnagel,     Die  nervosen  Nachkrankheiten  des  Abdominaltyphus.   Deutsches 
Arch.  f.  klin.  Med.,  Bd.  IX.,  1872,  p.  487. 


AND  COCCYGEAL   NERVES. 


669 


Fig.  117. 


characteristic.  Secondary  contractions  of  the  muscles  of  the 
calf  are  apt  to  occur,  and  then  the  gait  is  rendered  still  more 
peculiar  and  characteristic. 

The  part  played  by  the  several  muscles  in  producing  these 
symptoms  is  as  follows  :  Para- 
lysis of  the  tibialis  anticus 
limits  dorsal  flexion  and  adduc- 
tion of  the  foot,  and  the  inner 
border  and  the  point  of  the  foot 
can  no  longer  be  raised,  though 
these  movements  may  be  in 
part  vicariously  executed  by  the 
extensor  digitorum  communis, 
and  the  extensor  longus  pollicis. 
Paralysis  of  the  extensor  digi- 
torum communis  likewise  dimi- 
nishes dorsal  flexion  of  the  foot 
and  abduction  of  the  foot  in  the 
flexed  position,  and  renders  ex- 
tension of  the  basal  phalanges 
of  all  the  toes  impossible. 

Paralysis  of  the  extensor  lon- 
gus pollicis  diminishes  dorsal 
flexion  and  abolishes  the  power 
of  extending  the  great  toe. 
Paralysis  of  the  peroneus  lon- 
gus renders  abduction  of  the 
foot  in  the  extended  position 
impossible,  the  arch  of  the  foot 
becomes  flattened,  and  the  inner 
border  no  longer  touches  the 
ground  because  the  head  of  the 
first  metatarsal  bone  is  no 
longer  drawn  downwards.  A 
peculiar  kind  of  flat  foot  is  pro- 
duced, which  has  been  carefully 
described  by  Duchenne.^    If  the 


'  Duchenne.   L'Electrisation  localise'e, 
36  Edit.,  1872,  p.  989. 


Fig.  117.    Muscles  of  the  Front  of  the 
Leg  (from  Wilson). 

1,  Quadriceps  extensor  inserted  into 
the  patella. 

2,  Subcutaneous  surface  of  the  tibia. 

3,  Tibialis  anticus. 

4,  Extensor  longus  digitorum. 

5,  Extensor  proprius  pollicis. 

6,  Peroneus  tertius. 

7,  Peroneus  longus, 

8,  Peroneus  brevis. 

9,  9,  Borders  of  the  soleus  muscle. 

10,  Part  of  the  inner  belly  of  the  gas- 
trocnemius. 

11,  Extensor  brevis  digitorum ;  the  ten- 

don in  front  of  the  figure  is  that 
of  the  peroneus  tertius ;  that 
behind  it,  the  peroneus  brevis. 


670 


DISEASES   OF  THE   SACEAL 


Fig.  118. 


M 


peroneus  brevis  be  paralysed,  pure  abduction  of  the  foot  is  ren- 
dered impossible ;  it  can  only  then  be  accomplished  along  with 
dorsal  flexion  by  means  of  the  extensor  digitorum  communis,  or 
along  with  plantar  flexion  by  means  of  the  peroneus  longus. 
Paralysis  of  the  extensor  digitorum  communis  brevis.  impairs  the 
extens'ion  of  the  basal  phalanges  of  the  four  last  toes.  These 
various  paralyses  may  occur  in  an  isolated  manner,  or  they  may 

be  combined  in  various  ways, 
and  then  the  muscles  affected 
can  only  be  recognised  by  the 
most  careful  and  prolonged  in- 
vestigation. 

(h)  If  the  tibial  nerve  be 
paralysed,  all  the  muscles  at 
the  back  of  the  leg  are  affected, 
and  consequently  extension  of 
the  foot,  as  well  as  flexion  and 
lateral  movement  of  the  toes  is 
impossible.  Paralysis  of  the  gas- 
trocnemius and  soleus  prevents 
the  foot  from  being  extended, 
and  renders  it  impossible  for 
the  patient  to  stand  upon  the 
toes ;  a  hook-like  position  of 
the  foot  is  produced,  partly  in 
consequence  of  the  paralysis, 
and  partly  in  consequence  of 
secondary  contraction  of  the 
muscles  of  the  front  of  the  leg. 
Paralysis  of  the  tibialis  posti- 
cus diminishes  the  power  of 
adducting  the  foot,  or  of  raising 
its  inner  border.  Paralysis  of 
the  flexor  communis  digitorum 
renders  flexion  of  the  two  distal 
phalanges  of  the  toes  impossible. 
Paralysis  of  the  flexor  pollicis 
longus  renders  flexion  of  the 
great  toe  incomplete.    Paralysis 


Fig.  118.  Superficial  Muscles  of  the  Back 
of  the  Leg  (from  Wilson). 

1,  Tendon  of  biceps. 

2,  Tendons  of  inner  hamstrings. 

3,  Popliteal  space. 

4,  Gastrocnemius. 

5,  5,  Soleus. 

6,  Tendo  Achillis. 

7,  Tuberosity  of  os  calcis. 

8,  Tendons  of  the  peroneus  longus  and 

brevis. 

9,  Tendons  of  the  tibialis  posticus  and 

flexor  longus  digitorum. 


AXD  COCCYGEAL   NERVES. 


671 


of  the  adductor  and  abductor 
moving  the  great  toe  laterally, 
renders  flexion  of  the  first,  and 
extension  of  the  two  distal 
phalanges  of  the  toes,  as  well 
as  separation  of  the  toes,  im- 
possible, and  a  peculiar  claw- 
like position  is  thus  produced 
just  as  in  the  hand.  The  first 
phalanx  is  abnormally  extended, 
the  second  and  third  are  strongly 
flexed,  and  the  toes  no  longer 
touch  the  ground  with  their  bul- 
bous extremities.  Some  pain 
and  inconvenience  are  experi- 
enced after  long  standing  or 
walking,  but  the  functional  dis- 
turbance produced  is  relatively 
small. 

These  paralyses  of  the  mus- 
cles of  the  lower  extremities 
cause  various  anomalies  in  the 
position  of  the  foot  and  secon- 
dary alterations  in  the  joints, 
but  the  details  of  these  mal- 
formations will  be  found  in 
surgical  and  orthopoedic  works. 

If  the  trunk  of  the  sciatic 
nerve  be  afi'ected,  the  branches 
distributed  to  the  flexors  of 
the  leg,  the  semi-tendinosus, 
semi-membranosus,  and  biceps 
femoris  are  also  paralysed,  and 
the  patients  are  unable  to  flex 
the  leg  upon  the  thigh,  to 
approximate  the  heel  to  the 
gluteal  region,  or  to  offer  any 
resistance  when  an  attempt  is 
made  to  extend  the  leg. 


pollicis  abolishes  the  power  of 
while  paralysis  of  the  interossei 

Fig.  119. 


Fig.  119.   Deep  Layer  of  Muscles  of  the 
Back  of  the  Leg  (from  Wilson). 

1,  Lower  extremity  of  the  femur. 

2,  Ligamentum  posticum  Winslowii. 

3,  Tendon   of  the  semi-membranosus 

muscle.  Pinee -joint. 

4,  Internal   lateral    ligament    of    the 

5,  External  lateral  ligament. 

6,  Popliteus  muscle. 

7,  Flexor  longus  digitorum. 

8,  Tibialis  posticus. 

9,  Flexor  longus  pollicis. 

10,  Peroneus  longus. 

11,  Peroneus  bre vis. 

12,  Tendo    Achillis    divided    near  its 

insertion  into  the  os  calcis. 

13,  Tendons  of  the  tibialis  posticus  and 

flexor  longus  digitorum,  just  as 
they  are  about  to  pass  beneath 
the  internal  annular  ligament  of 
the  ankle  ;  the  interval  between 
the  latter  tendon  and  the  tendon 
of  the  flexor  longus  pollicis  is  for 
the  posterior  tibial  vessels  and 
nerve. 


672 


DISEASES   OF  THE   SACRAL 


Paralyses  of  the  sciatic  nerve  are  usually  accompanied  by 
disturbances  of  sensibility,  the  extent  of  which  depends  upon 
the  cause  of  the  paralysis.  When  the  paralysis  is  limited  to  the 
peroneal  region,  the  anaesthesia  is  limited  to  the  anterior  and 
external  side  of  the  leg,  the  dorsum  of  the  foot,  and  the  greater 
part  of  the  toes.     If  the  tibial  nerve  be  affected,  the  posterior 


Fig.  120. 


Ram.  inf.  N.  glut.,  inf.  pro  M. 

glut,  ludxiru 

Ner^.  iachiadicus    

Muse,  biceps  (Caput  longum) 

Muse,  biceps  (Caput  breve)  . . 


Nerv.  tibialis 


Nerv.  peroneus    

M.  gastrocuem.  exterims  . . . 


M.  soleua 


M.  adductor  magnua. 
M.  semi-tendinosus. 
M.  Bemi-membrauosua. 


M.  gastrocnem.  internua. 


surface  of  the  leg,  the  sole  of  the  foot,  and  the  plantar  surface  of 
the  toes  are  the  seats  of  the  aasesthesia.  The  region  of  the 
knee,  the  back  part  of  the  thigh,  and  ultimately  the  buttock 
and  perinseum  are  successively  affected  by  anaesthesia,  according 
as  the  lesion  is  situated  at  higher  levels  in  the  trunk  of  the 
nerve.  If  the  lesion  be  situated  in  the  hollow  of  the  sacrum  or 
in  the  cauda  equina,  the  anaesthesia  affects  the  whole  sacral 
region,  the  scrotum  (or  the  labia)  and  penis,  the  urethra, 
bladder,  and  rectum. 


AND   COCCYGEAL  NEEVES. 


673 


Vaso-motor  disturbances  are  usually  present  in  the  form  of 
cyanosis,  mottling,  and  coldness  of  the  skin  in  the  paralysed  leg. 
Increase  of  temperature  has  occasionally  been  observed  as  a 
transitory  symptom. 

Trophic  disturbances  are  not  unfrequent  in  cases  of  severe 
peripheral  paralysis  of  the  sciatic.  The  most  usual  of  these  are 
muscular  atrophy,  ulceration  of  the  skin,  eruptions  of  herpes  and 
pemphigus,  and  bed- sores  on  the  sacrum,  ankles,  and  heels. 

Fig.  121. 


M 

N.  oruralis   .-j~ :-/  |i 

N.  obturatorius Jyi4'',^^  .  ^  .     I'l 

M.  sartorius —  -'l'}iJ-'-^-^'j'.,  '-;  ."■,)i(l 

M.  adductor  long '--«  '-   .      ,  w||li 

Ram.  N.  oruralis  pro  M. '\^..±-^j^\^     \'"''^'iH 

quadricipit.  Vli/;i/j/,  y.].m 

M.  cruralis  

Bam.  X.  cruralis  pro  M.  _ . M'liii'i  J  '■'  , ,'  ,'i  'M 

vasto  int.  %.^;iX,        '•'■\'Vn 


M.  tensor,  fesciae  lat.  (Earn. 
N.  glutei  sup.). 

M.  tensor  fasciae  lat.    (Earn. 
N.  oruralis). 


M.  rectus  femor. 

M.  vastus  extern. 
M.  vastus  extern. 


The  diagnosis  between  peripheral  paralysis  of  the  sciatic 
nerve  and  the  paralysis  resulting  from  central  disease  is  not 
always  easy.  If  the  reflex  actions  are  preserved  in  the  paralysed 
muscles,  the  seat  of  the  paralysis  is  central,  although  the  con- 
verse does  not  hold  true,  since  the  reflex  action  is  sometimes 
abolished  in  spinal  disease.  The  reaction  of  degeneration  when 
associated  with  corresponding  sensory  disturbances  is  in  favour  of 
the  peripheral  origin  of  the  disease;  while,  if  it  be  not  associated 
with  any  disturbance  of  sensibility,  it  is  in  favour  of  its  spinal 
origin. 

The  prognosis  is  in  all  cases  doubtful,  depending  both  upon 
VOL.  I.  RR 


674 


DISEASES  OF  THE  SACRAL 


the  nature  of  the  cause  and  the  accompanying  trophic  dis- 
turbances, electrical  reactions,  and  various  other  factors.  In 
consequence  of  the  great  length  of  the  sciatic  nerve,  the  process 
of  regeneration  in  the  fibres  requires  a  long  time  before  it  is 


Fig.  122. 


M.  gastrocnemius  intemns 
M.  soleus 


M.  flex,  digitor.  commun.  long.. 


N.  tibialis 


M.  abductor  poUicis  . . 


completed,  so  that  in  traumatic  and  other  forms  of  paralysis  the 
affection  is  likely  to  be  of  long  duration,  and  often  proves 
incurable. 

Treatment. — After  removing  the  cause  of  the  affection,  where 
possible,  the  galvanic  current  should  be  employed  along  with  a 
graduated  system  of  gymnastics,  and  the  use  of  thermal  saline 
and  mud  baths.  Wheelhouse^  cut  down  upon,  resected,  and 
united  by  ligature  the  ends  of  a  sciatic  which  had  been  divided 


>  Wheelhouse.    The  Medical  Times  and  Ga^;ette.    VoL  II.,  1876,  p.  170. 


AND   COCCYGEAL  NERVES. 


675 


nine  months  previously,  and  the  patient  recovered  sensation 
and  a  considerable  degree  of  motor  power  in  the  paralysed 
extremity.     A  similar  operation  was  performed  by  Langenbeck^ 


Fig.  123. 


M.  peroneus  longns 
M.  tibialis  anticus 


M.  estens.  long.  polUois, 


Anterior  Tibial  Nerve. 
M.     extens.    digitor. 
brev. 


Mm.     interossei    pedis  J   "- — _J^ 
dorsales.  '  "~~ 


Nerv.  peroneus. 

M.  gastrocnem.  extern. 

M.  soleus. 

M.  extensor  long,  digitor 
communis. 


M.  peronens  brevis. 
JI.  soleus. 

M.  flexor  longus  poUicis. 


M.  extensor  digitor  com- 
mun.  brevis. 


M.      abductor      minimi 
digiti  ped. 


two  years  after  the  injury  to  the  nerve,  with  considerable  benefit 
to  the  patient.  Operative  measures  are  frequently  necessary  in 
order  to  remove  deformities,  but  the  reader  must  be  referred  for 
details  to  surgfical  treatises. 


'  Langenbeck.    The  Lancet.    Vol.  II.,  1876,  p.  589. 


Part  II.  — DISEASES    OF    THE    SYMPATHETIC 

SYSTEM. 


CHAPTER  I. 

SUMMARY    OF    THE    FUNCTIONS   OF    THE   SYMPATHETIC 

SYSTEM. 

The  sympathetic  system  of  nerves  consists  of  a  vertebral  and 
prevertebral  portion ;  the  vertebral  portion  is  composed  of  a  series 
of  ganglia,  united  by  a  longitudinal  cord  {Fig.  124,  IC  to  C) ;  it 
descends  along  each  side  of  the  vertebral  column  from  the  head 
to  the  coccyx.  The  prevertebral  portion  consists  of  the  numerous 
ganglia  and  plexuses  of  the  head,  chest,  abdomen,  and  pelvis. 

The  sympathetic  nerve  communicates  witii  the  cerebro-spinal  nerves 
immediately  at  their  exit  from  the  cranium  and  vertebral  canal.  It,  how- 
ever, unites  with  the  fomi:h  and  sixth  nerve  in  the  cavernous  sinus,  with 
the  olfactory  in  the  nose,  and  with  the  auditory  in  the  meatus  auditorius 
internus.  The  branches  of  distribution  accompany  the  arteries  which 
supply  the  different  organs,  so  that  aU  the  organs  of  the  body  are  suppHed 
by  branches  of  the  sympathetia 

§  302,  Functions  of  the  Sympathetic  System. 

1.  Reflex  Action.  —The  irritation  is  conveyed  by  afferent  fibres  to  one 
of  the  ganglia  of  the  sympathetic  and  then  reflected  through  efferent  fibres 
to  unstriped  muscular  fibres,  or  to  secretory  cells,  so  that  there  are  reflex 
secretory  as  weU  as  reflex  motor  actions. 

2.  Aiotomatie  Actions. — Rhythmical  discharges  originating  in  the  ganglia 
are  conveyed  by  efferent  fibres  to  plain  muscular  fibres  or  secretory  cells,  so 
that  there  are  both  motor  and  secretory  automatic  actions.  It  is  probable, 
however,  that  many  of  the  actions  now  regarded  as  automatic  will  prove  to 
be  reflex. 


678  FUNCTIONS  OF   THE   SYMPATHETIC  SYSTEM. 

Automatic  actions  are  under  the  regulation  of  inhibitory  and  stimu- 
lating or  accelerating  fibres. 

The  functions  of  the  sympathetic  system  may  be  divided  into 
those  of,  (1)  the  cervical,  and  (2)  the  thoracic  and  abdominal 
portions. 

(1)  Cervical  Portion  of  the  Sympathetic. 

(a)  Vaso-motor  fibres  for  the  corresponding  half  of  the  head.  Claude  Ber- 
nard showed  that  division  of  the  cervical  sympathetic  in  the  lower  animals 
produces  a  dilatation  of  the  vessels  of  the  head  and  neck  on  the  side 
operated  on,  along  with  an  elevation  of  temperature  which  ranges  from  4° 
to  6°  C.  Electrical  excitation  of  the  peripheral  end  of  the  divided  cervical 
sympathetic  contracts  the  dilated  vessels  of  the  head  and  neck,  and  lowers 
the  temperature  considerably  below  that  of  the  opposite  side. 

(6)  Oculo-pupillary  Fibres. — Division  of  the  cervical  sympathetic  is  also 
followed  by  contraction  of  the  pupil  (paralytic  myosis),  retraction  of  the 
globe  of  the  eye,  flattening  of  the  cornea,  and  decrease  in  the  size  of  the 
palpebral  fissure ;  while  irritation  of  the  peripheral  end  of  the  divided  sym- 
pathetic, on  the  other  hand,  produces  mydriasis,  prominence  of  the  globe 
(exophthalmos),  bulging  of  the  cornea,  and  enlargement  of  the  palpebral 
fissxire.  Both  the  vaso-motor  and  oculo-pupillary  fibres  have  their  origin, 
according  to  Claude  Bernard,^  in  the  spinal  cord,  but  the  two  sets  do 
not  issue  at  the  same  level.  Section  of  the  anterior  roots  of  the  two  first 
dorsal  nerves  gives  rise  to  the  oculo-pupillary,  but  not  to  the  vasculo- 
thermal  phenomena  ;  while  division  of  the  ascending  filaments  of  the 
thoracic  sympathetic  between  the  second  and  fourth  ribs  (in  dogs) 
produces  the  latter  without  the  former.  Bernard  consequently  inferred 
that  the  centres  of  the  oculo-pupillary  and  vaso-motor  fibres  exist 
at  different  levels  in  the  cord.  Budge  first  pointed  out  that  the  pupillary 
fibres  issue  from  the  spinal  cord  in  the  region  extending  from  the  point  of 
exit  of  the  sixth  cervical  to  that  of  the  second  dorsal  nerve,  and  he  conse- 
quently named  this  region  the  centrum  cilio-spmale  inferius.  Budge  believed 
that  there  was  a  second  centre  situated  higher  up  in  the  cord,  which  was 
connected  with  the  hypoglossal  nerve  by  a  communicating  filament,  and  this 
he  named  the  centrum  cilio-spmale  superius.  Claude  Bernard,  on  finding 
the  influence  of  Budge's  inferior  centre  on  the  pupil  and  eyeball,  named  it 
"  centrum  oeulo-pupillare." 

Contraction  of  the  pupil  after  section  of  the  cervical  sympathetic  is 
attributed  to  paralysis  of  the  dilator  pupillse  (paralytic  myosis);  while 
dilatation  of  the  pupil  (mydriasis)  on  irritation  of  the  sympathetic  is  attri- 
buted to  contraction  of  this  muscle.  The  exophthalmos,  following  irritation 
of  the  sympathetic,  is  usually  referred  to   the  action  of  the  unstriped 

1  Bernard  (C).  Le9ons  sur  la  physiologie  et  la  pathologic  du  systeme  nerveux. 
Tome  II.,  1858,  p.  473. 


FUNCTIONS   OF  THE   SYMPATHETIC   SYSTEM.  679 

muscle  of  the  orbit  (muscuhts  orbitalis),  which  was  discovered  by  H, 
MlUler/  and  is  situated  in  the  neighbourhood  of  the  sphenoidal  fissure.  This 
muscle,  although  imperfectly  developed  in  man,  is  an  important  structure 
in  ruminants ;  and  on  contraction,  it  throws  the  globe  of  the  eye  forwards. 
Other  unstriped  muscles  were  discovered  by  Miiller  in  the  u.pper  and 
lower  eyelids  of  men  and  the  mammalia,  and  these,  by  their  contraction, 
take  part  in  the  enlargement  of  the  palpebral  fissm-e,  and  in  the  protrusion 
of  the  globe  referred  to.  Prevost  and  Jolyet^  found  that  electrical  irritation 
of  the  superior  end  of  the  divided  cervical  sympathetic  caused  dilatation  of 
the  pupil,  congestion  of  the  conjimctiva,  separation  of  the  eyelids,  and 
protrusion  of  the  eyeball.  The  forward  movement  of  the  globe  begins 
some  seconds  after  excitation  of  the  sympathetic  ;  it  takes  place  in  a  slow 
and  gradual  manner,  continues  for  some  time  after  the  irritation  is  withdrawn, 
and  occurs  in  curarised  animals,  being  in  all  these  respects  like  the  move- 
ments caused  by  contraction  of  involuntary  muscles.  Miiller  supposed 
that  the  sympathetic  filaments  distributed  to  the  involuntary  muscles  of 
the  orbit  reached  them  through  the  spheno-palatine  ganglion,  but  Prevost^ 
has  shown  that  protrusion  of  the  eyeball  is  produced  by  galvanising  the 
cervical  sympathetic  after  the  ganglion  has  been  destroyed. 

After  division  of  the  cervical  sympathetic,  the  eye  is  drawn  inwards, 
from  paresis  of  the  external  rectus,  this  muscle  being  supplied  both  by  the 
abducens  nerve  and  by  filaments  from  the  ascending  branches  of  the 
superior  cervical  ganglion.  Some  authors  think  that  the  sympathetic 
exercises  a  tonic  influence  on  all  the  voluntary  muscles  of  the  ei/e,  and 
attribute  several  of  the  oculo-pupillary  phenomena  to  the  absence  of  this 
tonic  influence  when  the  sympathetic  is  divided. 

(c)  Trophic  and  Secretory  Fibres. — Irritation  of  the  sympathetic  is 
followed  by  contraction  of  the  vessels  of  the  salivary  glands,  and  provokes 
a  secretion  which  is  rich  in  the  specific  elements  of  saliva.  Ludwig  has 
shown  that  when  the  discharge  of  this  secretion  is  artificially  impeded 
the  pressure  in  the  excretory  duct  of  the  gland  may  be  greater  than  in  the 
arteries  supplying  it  ;  hence  it  may  be  inferred  that  the  cervical  sympa- 
thetic contains  special  secretory  branches  for  the  salivary  glands.  After 
extirpation  of  the  submaxillary  ganglion  a  continuous  secretion  occurs, 
which  may  be  increased  by  irritation  of  the  organs  of  taste,  but  which 
speedily  abates  on  the  occurrence  of  structural  changes  in  the  gland. 

The  nasal  mucous  membrane  appears  to  be  influenced  in  its  nutrition 
by  the  sympathetic  nerve.  Vulpian  found  that  irritation  of  the  spheno- 
palatine ganglion  was  followed  by  increased  secretion  of  the  corresponding 
side  of  the  nose. 

'  Miiller  (H.).  "  Sur  un  muscle  lisse  de  I'orbite  de  I'homme  et  des  mammifferes." 
Journal  de  Physiologie,  1860,  p.  176.  See  also  Turner.  "  On  a  non-striped  muscle 
connected  with  the  orbital  periosteum  of  man  and  mammals."  Nat,  Hist.  Review, 
Jan.,  1862. 

^  Prevost  et  Jolyet.  "  Note  sur  le  role  physiologique  de  la  gaine  fibro-musculaire 
de  I'orbite."    Comptes  Eendus,  Tome  LXV.,  1867,  p.  849. 

'Prevost  (J.  S.).  Archiv.  de  physiol.,  Tome  I.,  1868,  pp.  7  et  207;  Abstr. 
Schmidt's  Jahrb.,  Bd.  CXXXIX.,  1868,  p.  257. 


680 


FUNCTIONS  OF  THE  SYMPATHETIC   SYSTEM. 
Fig.  124. 


Fig.  124  (reduced  from  Flower).    Superior  Cervical  Ganglion  of  the  Sympathetic  :  its 
connections  and  branches. 

IC  to  rVO,  Branches  of  commuiiicatioii  to  four  upper  cervical  nerves. 
PS,  „  ,,  petrosal  ganglion. 

V  r,  „  „  ganglion  of  root  of  pneumogastric. 

V',  ,,  „  ganglion  of  trunk  of  pneumogastric. 

H,  „  5)  hypoglossal  nerve. 

CP,  Caiotid  plex'as. 


FUNCTIONS   OF  THE   SYMPATHETIC   SYSTEM.  681 

C'P,  Cavernous  plexus. 

CA,  Branches  accompanying  internal  carotid  artery. 

OG,         ,,        to  ophthalmic  ganglion. 

th,  To  t3Tnpanic  branch  of  glosso-pharjoigeal. 

3,  to  third  nerve. 

4,  ,,  fourth  nerve. 

5,  ,,  fifth  nerve. 

6,  , ,  sixth  nerve. 

V,  Vidian  nerve  to  spheno-palatine  ganglion. 
Sp,  Large  superficial  petrosal  from  facial  nerve.  _ 
EAC,  Accompanying  branches  of  external  carotid  artery. 
PP,  Pharyngeal  plexus,  formed  by  union  with  branches  of  vagus  and  glosso- 
pharyngeal nerves. 
SGr,  Superior  cardiac  nerve. 

The  Middle  Cervical,  or  Thyroid  Ganglion. 
IVC  to  VIC,  Branches  of  communication  with  fourth,  fifth,   and  sixth  cervical 
IT,  Inferior  thyroid  branches.  [nerves. 

MC,  Middle  cardiac  nerve. 
KL,  To  recurrent  laryngeal 

The  Inferior  Cervical  Ganglion. 
VIIC  to  VIIIC,  Branches  of  communication  with  seventh  and  eighth  cervical 
IC,  Inferior  cardiac  nerve.  [nerves. 

CP,  Cardiac  plexus. 
GW,  Ganglion  of  "Wrisberg. 
LCP,  Posterior,  or  left  coronary  plexus. 
KCP,  Anterior,  or  right  coronary  plexus. 

CRL,  Cardiac  branches  from  pneumogastric  or  recurrent  laryngeal  nerves. 

APP,  To  right  anterior  pulmonary  plexus. 

LPP,  To  left  anterior  pulmonary  plexus. 
ID  to  IID,  Branches  of  communication  from  the  first  to  the  twelfth  dorsal  nerves, 
a,  a.  To  aorta,  vertebra,  oesophagus,  and  posterior  pulmonary  plexus. 
GSN,  Great  splanchnic  nerve. 
SSN,  Small  splanchnic  nerve. 
SSN',  Smallest  splanchnic  nerve. 
D,  Diaphragm. 
PN,  Phrenic  nerve. 
SP,  Epigastric,  or  solar  plexus. 

CLP,  Cceliac  plexus. 

Cs,  Cystic  plexus. 

GSD,  Gastro-duodenal  plexus. 

C  s  P,  Gastric  or  coronary  plexus. 

Py,  Pyloric  plexus. 

Si)P,  Splenic  plexus. 

LGsE,  Left  gastro-epiploic  plexus. 

Per,  Pancreatic  plexus. 

HjoP,  Hepatic  plexus. 

V",  Branches  from  pneumogastric. 

DmP,  Diaphragmatic  plexus. 

SG,  Semilunar  ganglion. 

SEwP,  Supra-renal  plexus. 

EmP,  Renal  plexus. 

SpP,  Spermatic  plexus. 
SMP,  Superior  mesenteric  plexus. 

Mce,  Middle  colic. 

Rce,  Right  colic. 

Ice,  Ileo-colic. 
AP,  Aortic  plexus. 

IMP,  Inferior  mesenteric  plexus. 

LCI,  Left  colic  plexus. 

Ss,  Sigmoid  plexus. 

SHnt,  Superior  hsemorrhoidal  plexus. 
IL  to  VL,  Branches  of  communication  with  the  five  lumbar  nerves. 
IStoVS,  „  ,,  ,,        five  sacral  nerves. 

C,  ,,  ,.  <j         coccygeal  nerve. 

HP,  Hypogastric  plexus. 

IHP,  Pelvic,  or  inferior  hypogastric  plexus,  giving  branches  to  all  the 
nelvic  viscera. 


682  FUNCTIONS   OF   THE   STJ^IPATHETIC   SYSTEM. 

The  secretion  of  the  lachrymal  gland  appears  to  he  to  some  extent 
under  the  control  of  the  sympathetic. 

Brown-Se'quard  found  a  gi-adual  atrophy  of  the  eye  on  the  side  operated 
on  in  guinea-pigs  and  rabbits  after  section  of  the  cervical  sympathetic ; 
but  Eulenburg  and  Guttmann  did  not  find  any  trace  of  ophthalmia  or 
atrophy  of  the  eye  in  dogs  one  and  a  half  months  after  the  united  vagus 
and  sympathetic  were  cut.  Brown-Sequard  states  that  within  a  few  months 
after  division  of  the  cervical  sympathetic  in  guinea-pigs  and  rabbits 
he  observed  atrophy  of  the  corresponding  half  of  the  brain.  Vulpian 
subsequently  obtained  the  same  results. 

(d)  Cardiac  Excito- Motor  Braiiches.—(i.)  Accelerating  fibres  for  the 
heart  which  pass  in  the  superior,  middle,  and  inferior  cardiac  nerves  of 
the  sympathetic.  The  lowest  cervical  ganglion,  as  well  as  the  highest 
thoracic  ganglion,  conducts  accelerating  fibres  to  the  heart  through  the 
thu'd  branch  of  the  ganglion,  (ii.)  The  first  and  second  branches  are  the 
roots  of  the  depressor  nerve. 

(e)  Fibres  proceeding  to  the  cerebro-spinal  centres  which  call  into 
activity  the  cardiac  inhibitory  mechanism. 

(/)  Fibres  proceeding  to  the  cerebro-spinal  centres  which  stimulate  the 
vaso-motor  centre  (pressor  fibres). 

(2)  ■  Thovacic  and  Abdominal  Portion  of  the  Sympathetic. 

The  superior  thoracic  ganglion  (ganglion  stellatum)  conducts  accelerating 
fibres  to  the  heart,  which  reach  the  ganglion  by  way  of  the  cervical  sym- 
pathetic cord  and  the  root  accompanying  the  vertebral  artery  (Von  Bezold 
and  Bever). 

The  cardiac  plexus  is  constituted  of  fibres  passing  to  and  from  the 
heart,  and  belonging  to  the  vagus,  depressor,  and  sympathetic  nerves. 

The  splanchnic  nerves  contain  the  following  fibres : — 

1.  Inhibitory  fibres  for  the  intestine.  Irritation  of  the  splanchnic  in 
animals  arrests  the  movements  of  the  intestines. 

2.  Accelerating  fibres  for  the  intestine,  surmised  from  the  effect  of  post- 
mortem stimulation  (Heraiann). 

3.  Fibres  inhibiting  the  renal  secretion. 

4.  Yaso-motor  fibres  for  the  vascular  regions  of  the  abdomen. 

5.  Centripetal  fibres,  which  iuhibit  the  heart  in  a  reflex  manner, 
situated,  in  the  frog,  in  the  sympathetic  cord  (Bernstein). 

6.  Fibres,  u-ritation  of  which  causes  the  appearance  of  sugar  in  the  urine. 
Irritation  of  the  plexuses  of  the  sympathetic  situated  in  the  abdomen, 

as  well  as  irritation  of  the  cord,  causes  increased  movements  of  the  in- 
testines, bladder,  ureters,  uterus,  vesiculce  seminales,  and  spleen.  Section 
or  extirpation  of  the  sympathetic  cord  and  plexuses  produces  chiefly  cir- 
culatory and  nutritive  disturbance.  The  supra-renal  capsules  are  very 
rich  in  nerves,  and  contain  in  their  interior  cells  resembling  ganglion  cells. 


683 


CHAPTER    ir. 


THE    DISEASES    OF    THE    CEEVICAL    POKTION    OF    THE 
SYMPATHETIC. 

The  cervical  portion  of  the  sympathetic  includes  the  cilio-spinal 
region-  of  the  spinal  cord,  as  well  as  the  sympathetic  fibres  of  the 
rami  communicantes,  and  those  of  the  cervical  sympathetic  in 
the  neck  as  far  as  to  their  terminal  distribution.  The  pheno- 
mena produced  by  lesion  of  this  system  have  already  been 
considered  to  some  extent  when  the  disorders  of  the  pupil  were 
under  consideration,  but  it  is  now  necessary  to  enter  into  a  more 
detailed  description  of  them.  The  diseases  of  the  cervical  sym- 
pathetic may  be  divided  into  those  caused  by ;  (I.),  organic, 
and  (II.),  functional  lesions.  In  each  of  these  divisions  the 
resulting  phenomena  vary  according  as  the  lesion  is  (1)  an 
irritative,  or  (2)  a  depressive  one. 

(I.)-ORGANIC  AFFECTIONS  OF  THE  CERVICAL  PORTION  OF  THE 
SYMPATHETIC. 

§  303.  Symptoms. — (1)  Irritative  Phenomena. — When  the 
cervical  sympathetic  centre  in  the  medulla  oblongata  and  upper 
part  of  the  spinal  cord,  or  the  efferent  fibres  which  connect  it 
with  the  periphery,  are  irritated,  the  pupil  becomes  dilated 
(spasmodic  mydriasis) ;  the  eyeball  becomes  slightly  protruded 
(exophthalmos) ;  the  palpebral  aperture  is  increased  in  size ; 
the  skin  of  the  half  of  the  face  and  of  the  ear  on  the  affected 
side  is  pale,  and  cold  to  the  touch ;  and  the  temperature  in  the 
external  meatus,  and  probably  in  the  cavities  of  the  mouth  and 
nose,  on  that  side  is  lowered  as  compared  with  that  on  the 
opposite  side.     The  phenomena  of  irritation  of  the  sympathetic 


684  DISEASES   OF  THE   CERVICAL 

are  often  very  transient,  so  that  we  do  not  possess  very  accurate 
information  with  regard  to  the  state  of  the  secretions  in  such 
cases.  In  a  case  of  pachymeningitis  cervicalis  under  my  care  at 
present,  both  pupils  are  widely  dilated,  and  the  face  has  always 
an  oily  appearance  as  if  the  secretion  of  sweat  were,  not  so 
much  increased,  as  altered  in  quality.  I  have  observed  the  same 
appearance  in  other  cases  of  pachymeningitis,  and  it  was  a 
marked  feature  of  a  case  of  amyotrophic  lateral  sclerosis  which 
came  under  my  observation.  There  are  no  very  accurate  obser- 
vations with  regard  to  the  state  of  the  secretion  of  tears  or 
saliva,  and  that  from  the  mucous  membrane  of  the  nose  in 
irritative  lesions. 

(2)  Depressive  or  Paralytic  Phenomena. — In  destructive 
lesions  of  the  fibres  of  the  sympathetic  the  pupil  is  contracted 
(paralytic  myosis) ;  the  eyeball  is  retracted  or  falls  back  into  the 
orbit,  so  that  its  pressure  against  the  eyelids  is  lessened  and 
the  palpebral  fissure  consequently  becomes  narrower;  the 
temporal  artery  is  dilated ;  the  skin  of  the  face  and  side  of  the 
head  on  the  affected  side  may  be  congested,  especially  at  first ; 
the  temperature  in  the  external  meatus,  the  cavity  of  the  mouth 
and  the  nostril  is  increased  on  the  diseased  as  compared  with 
the  healthy  side ;  and  the  secretions  of  tears  and  of  saliva, 
that  from  the  mucous  membrane  of  the  nose,  and  the  secretion 
of  sweat  are  diminished  on  the  side  of  the  lesion.  No  pronounced 
trophic  disorders  have  been  met  with  in  paralysis  of  the  cervical 
sympathetic,  but  in  chronic  cases  the  skin  of  the  face  on  the 
side  of  the  lesion  may  look  more  flabby  and  wrinkled,  and  older 
than  that  of  the  opposite  side.  When  the  disease  has  become 
chronic  the  vessels  on  the  affected  side  of  the  face  may  cease  to 
be  dilated,  and  when  the  patient  exerts  himself  so  that  the 
cutaneous  vessels  of  the  body  generally  become  dilated  the 
healthy  half  of  the  face  becomes  flushed  and  covered  with  per- 
spiration, while  the  affected  half  retains  its  normal  appearance, 
and  remains  free  from  any  moisture.  In  a  case  of  paralysis  of 
the  sympathetic  fibres  in  the  neck  under  my  observation  at 
present,  caused  by  the  pressure  of  an  enlarged  goitre,  the 
patient  states  that  the  left  or  healthy  side  of  his  head  and  face 
is  often  bathed  in  perspiration,  while  the  right  side  is  quite  dry. 
The  diseased  side  may  also  remain  dry  when  the  patient  takes 


PORTION  OF   THE  SYMPATHETIC. 


685 


a  hot  bath,  but  in  the  case  of  rupture  of  the  brachial  plexus,  with 
oculo-pupillary  symptoms  already  described,  the  subcutaneous 
injection  of  pilocarpine  was  followed  by  perspiration  of  both  sides 
of  the  face,  while  the  skin  of  the  paralysed  arm  remained  quite 
dry.  Bilateral  paralysis  of  the  sympathetic  centres  in  the  medulla 
oblongata,  such  as  sometimes  occurs  in  progressive  bulbar  para- 
lysis, is  attended  by  a  greatly  increased  flow  of  viscid  saliva, 
corresponding  to  the  paralytic  secretion  obtained  in  experiments 
on  animals. 

§  804.  Morbid  Anatomy  and  Physiology. — The  organic 
lesions  of  the  sympathetic  may  be  divided  into  those  which  im- 
plicate the  (1)  centres  in  the  medulla  oblongata,  or  the  fibres  in 
their  descending  course  through  the  spinal  cord ;  and  (2)  the 
fibres  in  their  course  through  the  rami  communicantes  and 
cervical  sympathetic.  The  following  diagram  (Fig.  125)  will 
remind  the  reader  of  the  course  of  these  fibres. 

(1)   Lesions  of  the  Medulla  Oblongata  or  of  the  Cervical 


Fig.  125  (after  Erb).— A  A,  psychicalimpression ;  B,  centrum  optici;  C,  oculo-motor 
centre;  D,  dilator  centre  (spinal);  E,  iris;  G-,  optic  nerve;  H,  oculo-motor 
(sphincter);  I,  sympathetic  (dilator);  K,  L,  anterior  roots ;  MNO,  posterior 
roots ;  A,  seat  of  lesion  causing  reflex  pupillary  immobility ;  *,  probable  seat  of 
lesion  causing  myosin. 


686  DISEASES   OF  THE  CERVICAL 

Part  of  the  Spinal  Cord. — In  bulbar  paralysis  it  is  very  likely 
that  the  excessive  flow  of  saliva  present  in  the  advanced  stage 
of  the  disease  is  caused,  as  we  have  already  remarked,  by  paralysis 
of  the  sympathetic  centres  in  the  medulla  oblongata.  Dilatation 
of  both  pupils,  along  with  paralysis  of  the  four  extremities,  and 
a  remarkably  small  and  slow  pulse  (48  per  minute),  was  observed 
by  Rosenthal^  in  a  person  who  had  been  stabbed  in  the  neck  in 
the  neighbourhood  of  the  sixth  cervical  vertebra.  A  case  of 
cervical  pachymeningitis  is  at  present  under  my  care  in  i;he 
Royal  Infirmary  in  which  the  lesion  is  situated  opposite  the 
seventh  cervical  and  first  dorsal  vertebrae,  and  both  pupils  are 
widely  dilated ;  and  a  case  of  Potts'  curvature  is  recorded  by 
Eulenburg  and  Guttmann^  in  which  the  lesion  was  situated  in 
the  lower  cervical  region,  and  in  which  the  pupils  were  also 
dilated.  The  paralytic  phenomena  are,  however,  most  frequently 
met  with.  Contraction  of  the  pupils  was  observed  by  Hutchin- 
son^ in  a  case  of  fracture  of  the  seventh  cervical  vertebra,  and 
the  same  symptom  was  present  in  a  case  of  fracture  of  the  fourth 
cervical  vertebra  recently  under  the  care  of  my  colleague,  Mr. 
Heath.  Dr.  Ogle  observed  paralytic  myosis  in  five  cases  of  disease 
of  the  cervical  portion  of  the  spinal  cord.  In  a  case  of  hsemato- 
myelia  recorded  by  myself,*  in  which  the  upper  limit  of  the  lesion 
was  opposite  the  roots  of  the  eighth  cervical  nerve,  the  paralytic 
oculo-pupillary  phenomena  were  well  marked  on  the  affected 
side.  Out  of  a  hundred  cases  of  injury  to  the  spinal  cord  in  the 
neck,  Rendu^  found  the  state  of  the  pupil  noted  only  in  fifteen ; 
in  some  of  these  the  irritative  and  in  others  the  paralytic  phe- 
nomena predominated.  Contraction  of  the  pupil  was  observed 
by  Dr.  J.  Ogle^  in  five  cases  of  disease  of  the  spinal  cord. 

(2)  Lesions  of  the  Rami  Communicantes  or  of  the  Cervical 
Sympathetic. — The  irritative  phenomena  have  not  been  observed, 

^  Kosenthal.    Oesterr.  Zeitschrift  fiir  prakt.  Heilkunde,  1866,  No.  46. 
'^Eulenburg  and  Guttmann.      Die  Pathologie  des   Sympathicus  auf  physio- 
logischer  Grundlage.     1873.    p.  12. 

3  Hutchinson.     The  Lancet.    Vol.  I.,  1875,  pp.  214  and  787. 

*  Ptoss  (J.).    The  Practitioner.    Sept.,  1882,  p.  168. 

*  Rendu.  "  Des  troubles  functionels  du  grand  sympathique  observes  dans  les 
plaies  de  la  moelle  cervicale."    Arch.  gen.  de  ra6d.,  Sept.,  1869,  p.  286. 

«  Ogle  (J.).  "  On  the  influence  of  the  cervical  portion  of  the  sympathetic  nerve 
and  spinal  cord  upon  the  eye  and  its  appendages."  Medico-Chirurgical  Transactions, 
Vol.  XLI.,  1858,  p.  397. 


PORTION   OF  THE  SYMPATHETIC.  687 

SO  far  as  I  know,  from  lesion  of  the  rami  communicantes,  unless 
indeed  the  dilatation  of  the  pupil  in  cases  of  cervical  pachy- 
meningitis be  caused  by  irritation  of  these  fibres.  The  paralytic 
phenomena  are,  however,  well  marked  in  the  cases  of  rupture  of 
the  brachial  plexus  recorded  by  Paget,  Hutchinson,  SeeligmuUer, 
and  in  the  one  reported  already  by  myself. 

In  a  case  of  abscess  of  the  neck  recorded  by  Dr.  J.  Ogle,  the 
phenomena  of  irritation  alternated  with  those  of  paralysis,  and 
when  the  abscess  was  opened,  the  pupil,  which  was  previously 
alternately  contracted  and  dilated,  gradually  assumed  its  normal 
dimensions.  On  two  subsequent  occasions  abscesses,  which  formed 
in  the  same  region,  were  attended  by  similar  symptoms. 

Eulenburg  and  Guttmann^  mention  the  case  of  a  patient  suf- 
fering from  a  vascular  goitre,  limited  to  the  right  side,  in  which 
the  symptoms  were  extreme  mydriasis,  complete  immobility  of 
the  pupil,  considerable  exophthalmos,  and  loss  of  power  of  ac- 
commodation in  the  right  eye,  along  with  persistent  lowering  of 
the  temperature  of  the  auditory  meatus  of  the  same  side.  These 
symptoms  doubtless  resulted  from  the  irritation  of  the  cervical 
sympathetic  caused  by  the  goitre.  There  is  a  case  at  present  in 
the  Convalescent  Hospital  at  Cheadle  in  which  the  cervical 
glands,  especially  on  the  right  side,  are  considerably  enlarged ; 
on  that  side  the  pupil  is  relatively  dilated,  the  eye  is  prominent, 
the  cornea  is  very  convex,  the  intraocular  tension  is  increased, 
the  palpebral  aperture  is  wide,  and,  when  the  patient  looks 
horizontally  forwards,  a  rim  of  sclerotic  is  exposed  above  and 
below  the  cornea. 

The  case  of  a  smith  is  described  by  Seeligmiiller,^  who  received 
a  severe  blow  over  the  left  supra-clavicular  region ;  the  left  pupil 
was,  two  days  subsequently,  widely  dilated,  the  left  palpebral 
fissure  was  wider  than  the  right,  the  left  eyeball  was  prominent, 
and  the  left  side  of  the  head  and  neck  was  paler  than  the  corre- 
sponding parts  on  the  right  side. 

The  paralytic  are  much  more  frequently  observed  than  the 
irritative  phenomena.  The  case  of  a  soldier  is  reported  by  Weir 
Mitchell,^  who  came  under  his  observation  ten  weeks  after  a  gun- 

'  Eulenburg  and  Guttmann.     Op.  cit.,  p.  4. 
"  SeeligmiiUer  (A.).    Arch,  fur  Psychiat.     Bd.  V.,  1875,  p.  835. 
^  Mitchell,  Morehouse,  and  Keen.    Gunshot  wounds  and  other  injuries  of  nerves. 
1864.    p.  39. 


688  DISEASES  OF  THE   CERVICAL 

shot  wound  of  the  right  side  of  the  neck ;  the  right  pupil  was 
unusually  small;  there  were  myopia  of  the  right  eye,  slight 
ptosis,  apparent  sinking  of  the  outer  angle  of  the  lids,  decrease 
in  the  apparent  size  of  the  eyeball,  and  redness  of  the  conjunc- 
tiva, while  the  right  half  of  the  face  became  much  redder  after 
violent  exercise,  which  was  followed  by  pain  and  flashes  of  light 
in  the  eye  of  the  same  side.  More  or  less  similar  cases  have  been 
recorded  by  Seeligmiiller,^  Bernhardt,^  and  others. 

Contraction  of  the  pupil  was  observed  by  Willebrandt^  in  cases 
of  glandular  swelling  in  the  neck,  which  returned  to  its  normal 
size  when  the  tumours  were  reduced  by  friction  with  iodine  oint- 
ment. A  man  is  under  my  care  at  present  in  which  the  oculo- 
pupillary  symptoms  are  well  marked  on  the  right  side,  from 
compression  of  the  sympathetic  by  a  goitre  of  considerable  size. 
A  case  is  reported  by  Dr.  J.  Ogle*  in  which  compression  of 
the  cervical  sympathetic,  by  a  large  carcinomatous  growth  in 
the  neck,  gave  rise  to  contraction  of  the  pupil  on  the  affected 
side.  Similar  cases  have  been  recorded  by  VerneuiP  and  others. 
A  case  is  recorded  by  Dr.  W.  Ogle^  in  which  compression  of  the 
cervical  sympathetic  was  caused  by  a  cicatrix  and  enlarged  glaods 
in  the  right  side  of  the  neck ;  the  symptoms  present  were  con- 
traction of  the  pupil,  flattening  of  the  cornea,  injection  of  the 
conjunctiva,  congestion  of  the  ear  and  neck,  dilatation  of  the 
temporal  artery,  and  elevation  of  temperature  in  the  cavities  of 
the  mouth  and  nose  on  the  affected  side.  Compression  of  the 
sympathetic  is  not  unfrequently  caused  by  aneurism  of  the  aorta,'' 
innominate,  or  carotid  arteries.  The  case  of  a  child  is  recorded 
by  Payne^  in  which  the  symptoms  indicative  of  paralysis  of  the 
cervical  sympathetic  were  well  marked  on  the  left  side.     The 


1  Seeligmiiller.    Berl.  klin.  Wochenschr.    1872.    No.  4. 
''Bernhardt.    Berl.  klin.  Wochenschr.     1872.   No.  47  and  48. 
=  WiUebrandt.    Arch,  fur  Ophthal.    Bd.  I.,  1855,  p.  319. 

*  Ogle  (J.).     Loc.cit. 

*  Verneuil.     Gaz.  des  hop.    1864,  April  16. 

«  Ogle  (W.).  "  A  case  illustrating  the  physiology  and  pathology  of  the  cervical 
portion  of  the  sympathetic  nerves."  Medico-Chirurgical  Transactions,  Vol.  LII., 
1869,  p.  151. 

■'  Gairdner  (W.  T.).  "Case  of  aneurism  of  the  aorta  projecting  into  the  neck, 
and  accompanied  by  contraction  of  the  pupil  on  the  affected  side."  Edinburgh 
MedicalJournal,  Vol.  I.,  1855-56,  p.  143. 

^  Payne  (J.  F.).  "  Case  of  injury  to  the  sympathetic  nerve  in  the  neck."  St. 
Thomas's  Hospital  Reports,  Vol.  III.,  1873,  p.  171. 


PORTION   OF  THE   SYMPATHETIC.  689 

symptoms  dated  from  birth,  and  were  probably  caused  by  injury 
to  the  sympathetic  during  the  extraction  of  the  child  by  the 
forceps. 

{II.)-FUNCTIONAL   AFFECTIONS   OF   THE   CERVICAL   PORTION 
OF   THE    SYMPATHETIC. 

(1)   Cephalalgia  (Headache). 

§  305,  There  is  scarcely  any  disease,  or  symptom  of  disease, 
which  assumes  more  Protean  forms,  and  accompanies  more 
varied  conditions  than  headache.  It  is  doubtful  whether  head- 
ache ought  to  be  described  under  the  diseases  of  the  sympathetic 
nerves ;  indeed,  it  is  certain  that  some  forms  of  headache  are  not 
caused  by  disease  of  this  system  of  nerves  ;  but,  inasmuch  as  the 
vaso-motor  phenomena  give  a  decided  character  to  one  of  the 
principal  forms  of  the  affection — hemicrania — it  will  be  con- 
venient to  describe  briefly  all  kinds  of  headache  in  this  place. 
The  various  forms  of  trigeminal  and  occipital  neuralgia  are 
popularly  included  under  the  term  headache,  but  these  diseases 
must  be  excluded  from  any  precise  definition  of  the  affection. 

The  following  varieties  of  headache  may  be  distinguished  •} 

(1)  Ancemio  headache  is  of  a  dull  tensive  character,  usually 
affecting  the  temples,  brow,  and  vertex,  and  extending  along  the 
sagittal  suture.  It  is  relieved  by  rest  in  bed  and  the  recumbent 
posture,  and  rendered  worse  by  long  maintenance  of  the  erect 
posture.  There  is  a  disposition  to  faint,  general  pallor,  palpita- 
tion, dizziness,  and  uterine  disturbances  in  chlorotic  females.  All 
causes  which  exhaust  the  nervous  system,  as  anxiety,  night 
watching,  and  sexual  excesses,  aggravate  this  form  of  headache. 

(2)  Hypercemic  headache  usually  affects  the  whole  head  ;  the 
eyes  are  suffused ;  the  carotids  pulsate  strongly ;  and  the  head- 
ache is  accompanied  by  throbbing  and  sensations  of  pressure  and 
weight  in  the  head,  agitation,  hyperaesthesia,  and  illusions  of 
the  special  senses.  The  headache  is  sometimes  accompanied  by 
redness  and  heat  of  the  brow  and  vertex. 

(3)  Hysterical  headache  is  met  with  in  females,  and  is 
generally  accompanied  by  other  symptoms  of  hysteria.     This 

•  See  Symonds.  Gulstonian  Lectures  "  on  headache."  The  Medical  Times  and 
Gazette,  Vol.  I.,  1858,  pp.  285,  339,  392,  471,  and  495. 

VOL.  L  SS 


690  DISEASES   OF   THE   CERVICAL 

form  of  headache  is  on  the  one  hand  closely  allied  to  trigeminal 
neuralgia,  and  on  the  other  to  true  migraine.  The  pain  is  some- 
times diffused  and  deep  seated,  but  it  is  more  frequently  limited 
to  one  spot,  and  feels  as  if  a  nail  were  being  driven  through  the 
skull;  hence  it  is  called  clavus.  Hysterical  headache  is  in- 
creased in  severity  during  the  menstrual  period  and  by  mental 
worry,  whilst  it  is  removed  by  amusement  and  anything  which 
eno^ages  the  attention. 

(4)  Toxic  headaches  are  caused  by  various  poisons  circulating 
in  the  blood.  One  of  the  best  examples  of  this  form  of  headache 
is  that  which  follows  alcoholic  intoxication.  In  the  morning 
after  a  carouse  a  severe  headache  is  experienced,  which  is 
accompanied  by  a  feeling  of  pressure  and  weight,  chiefly  localised 
in  the  deeper  parts  of  the  eyes  and  at  the  base  of  the  brain. 
Severe  headaches  also  follow  the  action  of  narcotics  and  anaes- 
thetics. They  are  also  caused  by  over-crowded  rooms  and  the 
inhalation  of  various  gases,  as  carbonic  oxide  and  sulphuretted 
hydrogen.  Obstinate  cephalalgia  is  one  of  the  most  common 
symptoms  of  uraemia,  and  in  many  cases  of  granular  contracted 
kidney  headache  is  the  chief  symptom  complained  of  when  the 
patient  seeks  medical  advice  for  the  first  time.' 

(5)  Pyrexial  Headache. — Headache  is  also  a  frequent  symp- 
tom of  the  acute  infectious  diseases,  as  scarlet  and  typhoid  fevers, 
and  of  acute  inflammatory  diseases,  as  pneumonia.  This  form  of 
headache  is  probably  a  variety  of  the  congestive  or  hypersemic 
headache,  its  main  characteristic  being  that  it  is  attended  by  a 
febrile  temperature,  while  the  other  symptoms  with  which  it  is 
associated  do  not  indicate  that  an  intracranial  disease  is  present. 
The  headache  is  generally  moderate  in  intensity,  dull,  deep- 
seated,  increased  by  stooping  and  accompanied  by  a  feeling  of 
lightness  in  the  head,  and  not  unfrequently  by  delirium,  and, 
according  to  Jenner,^  the  headache  ceases  when  delirium  begins. 

(6)  Neurasthenic  headache  occurs  in  those  in  which  the  ner- 
vous system  is  exhausted  by  mental  anxiety  and  worry,  night 
watching,  and  other  depressing  circumstances.  General  anaemia, 
combined  with  circumstances  which  depress  and   exhaust   the 

'  Murchison  (C).  "The  Croonian  lectures  on  derangements  of  the  liver."  The 
Lancet,  Vol.  I.,  1874,  p.  538. 

*  Jenner.    The  Medical  Times  and  Gazette.     Vol.  II.,  1860,  p.  505. 


PORTION   OF  THE   SYMPATHETIC.  691 

nervous  system,  is  the  usual  cause  of  this  form  of  headache.  The 
pain  is  generally  deep-seated,  heavy,  dull,  and  oppressive,  but 
varies  considerably  in  its  characters.  It  is  often  attended  by  a 
feeling  of  pressure  and  tension  above  the  occiput,  and  is  at  times 
accompanied  by  great  sensitiveness  to  touch  in  that  region.  The 
patient  is  generally  compelled  to  suspend  for  a  time  all  mental 
work. 

(7)  Rheumatic  headache  consists  of  a  violent  and  tearing 
pain  localised  in  the  muscles  of  the  head,  or  in  the  fascia  of  the 
occipito- frontalis  muscle.  It  is  often  attended  with  marked 
tenderness  of  the  scalp,  and  is  usually  brought  on  by  exposure 
to  cold. 

(8)  Gowty  headache  takes  the  form  of  a  dull,  heavy  pain  in 
the  forehead,  and  is  generally  attended  by  great  depression  of 
spirits,  giddiness,  pain  and  fulness  in  the  right  hypochondrium, 
flatulence,  and  high-coloured  urine  loaded  with  lithates.  Intense 
neuralgiform  headaches,  which  are  often  called  gouty,  are  pro- 
bably in  most  cases  an  expression  of  commencing  granular 
changes  in  the  kidneys.  In  reference  to  these  headaches  Dr. 
Russell  Reynolds^  says,  "the  special  features  are  pain  on  one  side 
of  the  head,  usually  parietal  or  occipital,  '  grinding  habitually,' 
but  forced  into  almost  intolerable  severity  by  movement,  such  as 
the  jar  of  carriage  riding  or  running  down  the  stairs  of  a  house, 
and  this  without  any  over- sensitive  nerve-points,  without  tender- 
ness of  scalp,  and  without  any  aggravation  by  mental  exertion. 
It  is  not  affected  by  posture  or  food,  and  is  relieved  by  physical 
rest." 

(9)  Sytnpathetic  headache  may  supervene  on  disease  of  almost 
all  the  peripheral  organs,  although  it  is  most  commonly  associated 
with  diseases  of  the  digestive  and  sexual  organs,  Tbe  most 
common  form  of  this  variety  is  the  browache  of  gastric  catarrh, 
tut  headache  may  accompany  irritation  of  the  intestinal  canal  or 
of  the  uterus  and  ovaries.  This  is  probably  the  place  in  which 
to  mention  headache  caused  by  excessive  straining  of  the  eyes. 
This  form  of  headache  is  often  associated  with  vertigo,  insomnia, 
and  sickness,  and  occasionally  by  vomiting.  Headache  may  be 
caused  by  excessive  use  of  the  normal  eye,  but  it  is  much  more 
liable   to  be  induced  when  the  eye  is  deficient  as  an  optical 

»  Reynolds  (R.).    The  British  Medical  Journal.    Vol.  II.,  1877,  p.  842. 


692  DISEASES  OF  THE   CERVICAL 

instrument,  and  it  is  especially  liable  to  occur  in  disorders  of 
accommodation.^  In  cases  of  headache  of  obscure  origin,  and 
more  especially  when  it  is  found  to  supervene  or  become  intensi- 
fied when  the  patient  begins  to  read  or  write,  the  state  of  vision 
should  be  carefully  investigated  by  an  ophthalmologist.^ 

(10)  Syphilitic  headache  is  so  important  as  to  deserve  special 
mention.  An  outburst  of  cerebral  syphilis  is  generally  preceded 
for  many  weeks  by  an  intense  and  persistent  headache.  The 
pain  is  deep-seated  and  severe,  and  is  either  attended  by  a  feeling 
of  weight  on  the  vertex  or  a  sense  of  constriction  as  if  the  head 
were  held  fast  in  a  vice.  The  patient  often  compares  the  pain 
to  that  which  he  imagines  would  be  caused  by  successive  blows 
struck  on  the  head  with  a  heavy  mallet.^  The  pain  is  sometimes 
distinctly  circumscribed  to  a  limited  portion  of  the  head ;  but,  as 
a  rule,  it  is  more  diffused,  and  may  then  occupy  either  the  frontal, 
temporal,  or  occipital  region.  It  invades  the  whole  head  only  on 
rare  occasions.  One  of  the  chief  characteristics  of  the  headache 
is  that  it  is  constant,  and  never  completely  intermits,  although  it- 
is  liable  to  paroxysmal  exacerbations  of  great  severity.  Even  in 
the  slighter  degrees  of  the  affection  the  patient  suffers  greatly ; 
he  becomes  sad,  morose,  excitable,  and  the  mental  faculties 
are  so  depressed  as  almost  to  incapacitate  him  for  any  work. 
In  the  severer  forms  of  the  affection  the  pain  increases  to  the 
most  agonising  intensity,  and  the  head  becomes  so  sensitive  to 
the  touch  that  the  patient  is  unable  to  lay  it  on  a  pillow.  He 
sits  up  in  bed  grasping  his  head  between  his  hands,  groaning  or 
even  screaming  out.  Syphilitic  headache  is  often  accompanied 
by  an  ephemeral  delirium,  and  in  the  severest  varieties  the 
patient  may  become  maniacal.  The  headache  is  caused  either 
bv  syphilitic  disease  of  the  membranes  of  the  brain,  or  by  syphi- 
litic osteitis,  or  by  both  conditions  combined.* 

Another  characteristic  of  the  syphilitic  headache  is  that  it  is 
liable  to  nocturnal  exacerbations.    The  headache  may  be  tolerable 


»  Carter  (J.  B.).     Clinical  Society's  Transactions.    Vol.  VIII.,  1875,  p.  12. 

^  Mitchell  (S.  W.).  "  Headaches  from  eye  strain,"  The  American  Journal  of 
the  Medical  Sciences,  Vol.  I.,  1876,  p.  363. 

^  Fournier,  La  Syphilis  du  Cerveau.  1879.  p.  88.  See  also  Goolden  (R.  H.). 
*'  Periosteal  disease  affecting  the  dura  mater."    The  Lancet,  Vol.  II.,  1851,  p.  149. 

"Jackson  (Hua;hlings),  "On  a  case  of  intracranial  syphilis."  The  Lancet, 
Vol  I.,  1880,  p.  275. 


PORTION   OF  THE   SYMPATHETIC.  C93 

during  the  day,  but  it  usually  rises  to  such  intensity  at  night 
that  the  patient  is  prevented  from  sleeping ;  so  that  those  who 
suffer  from  syphilitic  headache  usually  assert  that  they  have 
not  slept  for  weeks  previously.  The  nocturnal  exacerbations  do 
not,  however,  always  occur ;  and  consequently  an  intense  and 
persistent  headache  should  of  itself  suggest  the  possibility  of 
syphilis. 

(11)  Organic  Headache. — The  severe  headache  which  ac- 
companies structural  disease  within  the  cranium  may  be  called 
organic  headache.^  Intense  headache  of  a  fixed  character  is  one 
of  the  most  constant  symptoms  of  intracranial  tumours.  Dr. 
Hughlings  Jackson  thinks  that  frontal  headache  is  generally 
referrible  to  abdominal  affections,  vertical  headache  to  cerebral 
disturbance,  and  occipital  pains  to  disorders  of  the  circulation, 
and  more  especially  to  anaemia,  and  Professor  Laycock^  adopted 
a  somewhat  similar  view.  But  the  pain  of  cerebral  disease  may 
be  frontal  or  occipital,  or  it  may  extend  over  the  whole  head, 
although  it  is  more  frequently  deeply  seated  in  one  spot.  The 
pain  is  persistent  and  continuous,  but  liable  to  paroxysmal 
exacerbations  of  great  severity.  It  is  often  attended  with  ten- 
derness of  the  scalp,  and  pain  may  be  elicited  on  percussing  the 
skull  over  the  seat  of  the  tumour. 

Any  disease  of  the  brain,  or  of  its  membranes,  may  be  asso- 
ciated with  headache,  and  it  is  probable  that  the  pain  is  more 
severe  when  the  cortex  of  the  brain  and  the  membranes  are 
affected  than  when  the  lesion  is  more  deeply  seated.  It  must, 
however,  be  remembered  that  a  deeply-seated  lesion,  attended 
by  increase  of  volume,  such  as  a  cerebral  tumour,  will  cause 
irritation  of  the  cortex  and  membranes  of  the  brain.  Headache 
is  also  a  constant  symptom  of  inflammatory  and  ulcerative  pro- 
cesses in  the  skull  and  adjoining  tissues,  such  as  catarrh  of  the 
frontal  and  sphenoidal  sinuses,  and  of  inflammatory  affections  of 
the  scalp,  the  fascia  of  the  occipito-frontalis  muscle,  and  the  peri- 
cranium. It  is  likewise  an  almost  constant  symptom  of  syphilitic 
diseases  of  the  skull,  caries  of  the  petrous  portion  of  the  tem- 
poral bone,  and  certain  lesions  of  the  eye  and  ear. 

'  Day  (W.  H.).     Headaches :  their  nature,  causes,  and  treatment.   1877.   p.  203. 
^  Laycock.     "  Lectures  on  the  clinical  observation  of  diseases  of  the  brain  and 
nervous  system."    The  Medical  Times  and  Gazette,  Vol.  I.,  1871,  p.  152. 


694  DISEASES  OF  THE   CERVICAL 

Hemicrania  is  the  only  form  of  headache  which  remains  to  be 
described,  but  its  importance  is  so  great  as  to  deserve  separate  and 
extended  consideration. 

HEMICEANIA. 

(migraine — SICK   HEADACHE.) 

Hemicrania  consists  of  spontaneous  attacks  of  pain  in  the  head 
occurring  in  paroxysms,  and  usually  more  marked  on  one  side  of 
the  head,  although  it  may  reach  to  the  opposite  side. 

§  306.  Etiology. — Like  many  other  nervous  affections  hemi- 
crania is  hereditary,  being  often  transmitted  from  parent  to  child. 
It  very  generally  follows  the  female  line,  being  usually  trans- 
mitted from  mother  to  daughter.  The  inheritance  of  hemicrania 
is  not,  however,  always  direct;  but  a  certain  neurotic  tendency  is 
transmitted,  of  which  headache  becomes  one  of  the  manifesta- 
tions. In  families  with  tendencies  to  neuropathic  diseases  in- 
dividual members  suffer  from  migraine,  while  others  are  attacked 
with  epilepsy,  insanity,  and  other  diseases  of  the  same  class.^  The 
severest  and  most  intractable  case  of  migraine  that  I  have  ever 
seen  was  in  a  lady  whose  mother  was  an  epileptic.  The  female 
sex  is  affected  with  hemicrania  in  about  the  proportion  of  five  to 
one  of  the  male  sex.  The  predisposition  to  neuralgias  in  general 
is  greater  among  women  than  among  men,  but  the  disproportion 
between  the  liability  of  the  sexes  is  not  nearly  so  great  in  the 
other  neuralgias  as  in  hemicrania. 

With  respect  to  age,  the  period  of  youth  is  decidedly  favour- 
able to  the  development  of  the  disease.  The  statement  qf  Tissot,^ 
that  a  person  who  is  not  attacked  with  migraine  before  bis 
twenty-fifth  year  will  be  exempt  from  the  disease  for  the  re- 
mainder of  his  life,  may  be  accepted  as  a  good  practical  maxim, 
although  it  is  liable  to  many  exceptions.  When  there  is 
a  strong  hereditary  predisposition  to  the  disease  it  may  appear 
during  childhood ;  the  age  of  puberty  is  especially  favourable 
to  its  development,  and  the  majority  of  cases  of  hemicrania 
make  their  appearance  about  this  time. 

*  Anstie  (F.  E.).  Neuralgia,  and  the  diseases  that  resemble  it.  London,  1872. 
p.  119.     See  also  The  Practitioner,  Vol.  X.,  1873,  p.  31. 

*  Tissot.     (Euvres,  Nouvelle  Edit.     Tome  XIII.,  1790,  p.  95. 


PORTION   OF  THE  SYMPATHETIC.  695 

The  iDfluence  of  various  dyscrasise  in  the  production  of  hemi- 
crania  is  not  readily  detected.  Patients  suffering  from  anaemia, 
chlorosis,  and  constitutional  syphilis,  or  who  have  rheumatic  or 
gouty  constitutions,  are  liable  to  be  attacked  with  hemicrania ; 
but  it  is  doubtful  whether  they  are  proportionately  more  fre- 
quently attacked  than  other  persons.  Hemicrania  is  also  met 
with  in  those  who  are  subject  to  hysteria ;  but  this  does  not 
happen  nearly  so  frequently  as  has  been  supposed.  The  reason 
that  the  association  between  hysteria  and  hemicrania  has  been 
supposed  to  be  so  frequent  is  that  the  "clavus"  of  hysterical 
patients  has  been  mistaken  for  true  migraine. 

Individuals  engaged  in  occupations  demanding  excessive 
mental  activity  doubtless  suffer  from  hemicrania  more  fre- 
quently than  those  whose  occupations  lead  them  to  exercise  their 
muscular  system ;  but,  with  this  exception,  hemicrania  appears 
to  occur  with  about  equal  frequency  in  all  professions  and  ranks 
of  life.  Of  the  exciting  causes  of  hemicrania  very  little  is 
known.  It  is,  however,  so  frequently  associated  with  gastric  dis- 
turbance that  it  has  been  called  sick  headache,  but  whether  the 
digestive  derangement  be  a  cause  or  an  effect  of  the  headache  is 
very  difficult  to  determine.  It  is  probable  that  disturbances  in 
the  circulation  of  the  blood  may  be  to  a  certain  extent  operative 
in  the  production  of  the  disease,  inasmuch  as  women  during  the 
time  of  menstruation  are  specially  liable  to  be  attacked,  and  it 
not  unfrequently  disappears  after  the  climacteric  period. 

§  307.  Symptoms. — Hemicrania  consists  of  paroxysms  of  head- 
ache separated  by  intervals  of  shorter  or  longer  duration,  which 
are  usually  free  from  symptoms.  The  attack  is  frequently  pre- 
ceded by  premonitory  symptoms.  From  twelve  to  twenty-four 
hours  before  the  attack  the  patient  feels  depressed  and  weary, 
along  with  a  sense  of  pressure  in  the  head  and  an  indisposition  to 
continued  work.  The  patient  feels  a  chill  and  nausea,  and  may 
have  attacks  of  yawning  or  sneezing,  and  not  unfrequently  he 
complains  of  muscae  volitantes  and  tinnitus  aurium. 

The  headache  of  migraine  is  often  preceded  by  an  attack  of 
scintillating  scotoma^  (§  209)  and  by  various  other  interesting 
symptoms.    The  most  usual  of  these  are  transitory  impairment  of 

*  Liveing.      On  migraine  and  sick  headache.    1873.    p.  81  et  seq. 


696  DISEASES  OF   THE   CERVICAL 

cutaneous  sensibility,  along  with  tingling,  numbness,  and  formi- 
cation. There  may  also  be  deafness,  loss  of  taste,  embarrassment 
of  speech,  momentary  incoherence,  transitory  paresis  of  one  of 
the  limbs,  vertigo,  and  nausea,^  The  patient  may  also  suffer  from 
indistinct  vision,  hemiopia,  or  muscse  volitantes,  and  tinnitus 
aurium ;  there  is  a  bitter  taste  in  the  mouth,  which  is  usually 
attributed  to  concomitant  derangement  of  the  stomach  or  liver, 
but  which  is  much  more  likely  to  be  due  to  functional  disturbance 
of  the  nerves  of  taste. 

The  characteristic  pain  comes  on  by  degrees  in  the  course  of 
the  day,  and  almost  never  with  the  lightning  rapidity  of  the 
pain  of  neuralgia.  The  patient  generally  awakes  with  the  pain 
in  the  morning,  and  in  these  cases  he  has  not  unfrequently  ex- 
perienced great  drowsiness  the  previous  evening.  The  pain  is 
confined  to  one-half  of  the  cranium,  but  it  is  not  generally 
strictly  so  limited.  It  may  begin  as  a  dull  pain  over  the  fore- 
head, and,  as  it  increases  in  severity,  it  passes  down  to  one  eye, 
and  remains  fixed  over  the  temple.  Occasionally  it  is  seated 
at  the  top  or  back  of  the  head.^  The  left  side  is  more  frequently 
attacked  than  the  right,  the  frequency  being,  according  to 
Eulenburg,  in  the  proportion  of  two  to  one.  The  attacks  occur 
by  turns  on  each  side  of  the  head  in  some  individuals,  but  in 
these  cases  one  side  of  the  head  is  attacked  oftener  and  more 
severely  than  the  other.  Eulenburg^  gives  the  name  of  hemi- 
crania  alternans  to  these  cases,  and  he  thinks  that  this  variety 
is  specially  liable  to  be  associated  with  vaso -motor  disturbances. 
The  pain  is  sometimes  so  violent  as  to  deserve  the  name  of 
neuralgia ;  but,  instead  of  being  tearing  or  darting,  as  in  true 
neuralgia,  patients  describe  it  as  being  dull,  burning,  or  bursting, 
and  it  is  frequently  associated  with  an  intense  feeling  of  sickness. 
With  every  beat  of  the  heart  the  patient  feels  a  throb  of  pain  in 
the  head ;  and  the  slightest  movement  which  excites  the  circu- 
lation, even  raising  the  head  from  the  pillow,  or  the  exertion  of 
talking,  augments  the  throbbing  pain,  so  that  it  becomes  almost 
unendurable. 

'  See  Allbutt  (T.  C  ).  "  On  megrim,  sick  headache,  and  some  allied  disorders." 
British  and  Foreign  Medico-Chirurgical  Review,  Vol.  I.,  1874,  p.  315. 

"■  Wilks  (S.).     The  Medical  Times  and  Gazette.    Vol.  I.,  1869,  p.  I. 

^Eulenburg.  Lehrbuch  der  Nervenkrankheiten.  2^  aufl.,  Theil.  II.,  1878, 
p.  264. 


PORTION   OF   THE   SYMPATHETIC.  697 

There  is  complete  anorexia,  the  patient  being  usually  unable 
to  swallow  any  food  for  twenty-four  hours;  but  this  rule  is  not 
without  its  exceptions,  since  some  patients  eat  as  usual  notwith- 
standing the  headache.  In  some  cases  there  may  be  more  or 
less  jaundice,  along  with  the  physical  signs  of  a  slight  degree  of 
congestion  of  the  liver ;  the  patient  suffers  from  continuous 
nausea,  and  the  attack  often  terminates  by  the  ejection  of  large 
quantities  of  bile  and  other  fluids  from  the  stomach.^ 

Painful  "points  are  absent  in  true  hemicrania,  although  some- 
times a  spot  above  the  tuber  parietale  is  tender  on  pressure. 
Cutaneous  hyperalgesia  is  not  an  uncommon  symptom  during 
an  attack  of  migraine,  the  greater  part  of  the  forehead,  temples, 
and  parietal  regions  being  in  many  cases  very  sensitive  to  light 
touches,  while  deep  diffused  pressure  affords  relief. 

It  has  also  been  shown,  by  Berger,^  that  a  morbid  acuteness 
of  the  sense  of  touch  (hyperpselaphesia)  may  be  present.  He 
found  that  the  diameter  of  the  circle  of  perception  was  only  one 
line  in  the  frontal  region  of  the  rigbt  or  affected  side ;  while  it 
was  four  lines  at  the  corresponding  point  in  the  opposite  or 
unaffected  side.  Variations  of  temperature  of  0"4°  C.  were 
perceived  on  the  right  side,  and  of  0  8°  C.  on  the  left  or  sound 
side,  while  the  electro-cutaneous  test  indicated  increased  sensi- 
bility on  the  affected  side. 

Deep  pressure  causes  decided  pain  when  applied  over  the 
region  of  the  superior  or  middle  cervical  ganglion  of  the  sym- 
pathetic; and  at  times  when  applied  to  the  spinous  processes  of 
the  lowest  cervical  and  uppermost  dorsal  vertebrae — the  cilio- 
spinal  region  of  the  cord. 

Children  are  liable  to  suffer  from  periodically  recurring  head- 
aches. They  occur  most  frequently  during  the  period  of  the 
second  dentition,  and  are  generally  associated  with  other  nervous 
symptoms.  The  child  is  excitable,  peevish,  or  fretful ;  his  rest  is 
disturbed  by  dreams  and  night-terrors ;  the  appetite  is  capricious  ; 
there  is  grinding  of  the  teeth  at  night;  and  the  attack  is  attended 
by  nausea  and  often  by  retching.^     These  headaches  are  accom- 

•  See  Allbutt  (T.  C).    "  On  Migraine."    The  Practitioner,  Vol.  X.,  1873,  p.  25. 

^  Berber  (O.).  "  Zur  Pathogenese  der  Hemicranie."  Virchow's  Archiv.,  LIX., 
1874,  p.  324. 

^  See  Warner  (F.).  "Recurrent  headaches  in  children,  and  associated  patho- 
logical conditions."    The  British  Medical  Journal,  Vol.  11.,  1879,  p.  889. 


698  DISEASES   OF   THE   CERVICAL 

panied  in  some  cases  by  somnambulism,  or  they  may  be  the 
precursors  of  an  attack  of  chorea.  The  facts  that  these  headaches 
generally  occur  in  the  children  of  neuropathic  parents,  and  that 
they  are  usually  accompanied  by  other  nervous  symptoms,  render 
it  likely  that  they  are  of  the  nature  of  migraine,  although  the 
pain  does  not  assume  a  distinctly  unilateral  character.  This 
form  of  headache  is  generally  situated  in  the  forehead,  and  the 
pain  is  sometimes  so  severe  and  persistent  that  the  presence  of 
organic  diseases,  such  as  acute  hydrocephalus,  is  suspected,  but 
as  West^  remarks,  the  periodical  headaches  of  children  occur,  as 
a  rule,  at  a  later  period  of  life  than  acute  hydrocephalus.  The 
headaches  of  children  are  sometimes  caused  by  defects  of  ocular 
accommodation,  and  in  all  such  cases  the  condition  of  the  eyes 
should  be  carefully  investigated. 

§  308.  Varieties. — The  vaso-motor  disturbances  during  tlie  paroxysms  of 
hemicrania  are  so  marked  that  they  give  a  decided  character  to  the  attack. 
Three  varieties  of  these  may  be  distinguished.  The  first  form  is  mainly 
characterised  by  vascular  contraction,  hence  the  attacks  in  which  this 
variety  occurs  are  called  hemicrania  spastica  or  sympathico-tonica;  the 
second  is  characterised  by  vascular  dilatation,  and  the  attacks  in  vfhich  this 
variety  occurs  as  a  concomitant  symptom  Eulenbiu-g  proposes  to  call  hemi- 
crania angio-paralytica  or  neuro-paralytica ;  and  the  third  variety  is  a  mixed 
form,  in  which  the  symptoms  of  the  sympathico-tonic  and  neuro-paralytic 
varieties  alternate.  There  are  cases  of  migraine  which  present  no  appre- 
ciable local  vaso-motor  disturbances. 

1.  Hemicrania  spastica  or  Sympathico-tonica. — At  the  height  of  the 
attack  the  face  is  pale  on  the  affected  side,  the  eye  is  prominent,  the  pupil 
is  dilated,  and  the  temporal  artery  feels  like  a  hard  cord.  The  ear  on  the 
affected  side  is  pale  and  colder  than  the  other,  the  difference  in  temperature 
between  the  two  being,  according  to  Eulenburg,  from  0'4°C.  to  O'e^C.  taken  in 
the  external  meatus.  Compression  of  the  carotid  on  the  affected  side  aug- 
ments, and  on  that  of  the  unaffected  side  diminishes  the  pain.  The  sali- 
vary secretion  becomes  very  viscid,  and  it  is  greatly  increased  in  quantity. 
Berger  observed  over  two  pounds  discharged  in  a  single  attack.  The  pain 
is  aggravated  by  every  circumstance  which  excites  the  circulation  and  in- 
creases the  arterial  tension.  Towards  the  end  of  the  attack  the  affected 
side  of  the  face  and  the  ear  become  reddened,  and  this  is  accompanied  by  a 
sensation  of  heat  and  a  rise  in  temperature,  redness  of  the  conjunctiva, 
lachrymation,  and  sometimes  contraction  of  the  pupil.  A  general  feeling 
of  warmth  is  felt,  the  heart  palpitates,  there  is  vomiting,  an  abundant 

1  West  (C.)  "  On  cerebral  symptoms  independent  of  cerebral  disease."  The 
Medical  Times  and  Gazette,  Vol,  I.,  1861,  p.  354. 


PORTION   OF  THE  SYMPATHETIC.  699 

discharge  of  watery  iirine,  and  sometimes  even  a  watery  discharge  fi"om 
the  bowels. 

2,  Hemicrania  Angio-paralytica  or  Neuro-paralytica}  — At  the  height 
of  the  attack  the  affected  side  of  the  face  is  red,  hot,  and  turgid,  the 
conjunctiva  is  injected,  the  pupil  is  contracted,  and  there  is  an  increased 
secretion  of  tears.  At  times  there  is  narrowing  of  the  palpebral  fissure, 
retraction  of  the  globe,  and  a  falling  of  the  upper  hd,  along  with  difficulty 
in  performing  its  movements.  The  ear  on  the  affected  side  is  red,  and  its 
temperature  is  from  0*2°  C.  to  0*4°  C.  above  that  of  the  opposite  ear.  The 
temporal  artery  is  enlarged  and  beats  with  unusual  force.  Compression  of 
the  carotid  on  the  affected  side  eases,  and  of  that  of  the  opposite  side  aggra- 
vates the  pain.^  Sometimes  the  radial  artery  is  small  and  contracted,  and 
the  pulse  slow,  beating  from  48  to  56  times  a  minute,  but  these  symptoms 
are  not  always  present.  Towards  the  end  of  the  attack  the  affected  side  of 
the  face  becomes  paler,  and  the  other  phenomena  gradually  pass  off. 

3.  The  mixed  form  of  the  affection  requires  no  special  mention.  In 
cases  observed  by  Berger,  the  neuro-paralytic  attacks  ran  a  much  milder 
covu-se  than  the  spastic  attacks,  and  especially  with  less  vomiting. 

§  309.  Course,  Duration,  and  Terminations. — The  duration 
of  the  attack  of  migraine  is  very  variable.  It  usually  lasts  from 
a  few  hours  to  half  a  day,  but  continues  at  times  a  whole  day,  or 
several  days,  with  remissions  and  exacerbations.  If  the  pain  be 
present  on  waking,  it  gradually  wears  off  towards  evening ;  the 
patient  feels  exhausted  and  falls  into  a  sleep,  from  which  he 
awakes  generally  free  from  pain.  If  it  should  come  on  during 
the  day,  it  gradually  increases  in  severity,  and  sleep  is  rendered 
impossible.  It  is  sometimes  aggravated  by  the  recumbent 
position,  the  sitting  or  upright  posture  being  the  only  one  in 
which  the  patient  can  endure  his  sufferings.^  The  attacks  not 
unfrequently  recur  with  great  regularity  at  intervals  of  three 
or  four  weeks.  In  the  female  sex  the  attacks  are  often  coin- 
cident with  the  catamenia,  but  this  is  by  no  means  always 
the  case.  The  intervals  are,  as  a  rule,  free  from  pain,  if  we 
except  a  slight  tenderness  over  the  region  of  the  superior  cer- 
vical ganglion  and  the  spinous  processes  of  the  superior  cervical 
vertebrae.     The  attacks  may  be  aggravated  as  well  as  induced  by 

'  See  Eulenburg.  Art.  "Vaso-motor  and  trophic  neuroses."  Ziemssen's  Cyclo- 
paedia, Vol.  XIV.,  1878,  p.  16. 

^  See  MoUendorfiE.  "  Ueber  hemicranie."  Virchow'a  Archives,  Bd.  XLI.,  1867, 
p.  387. 

^  Wilks  (S.).     Diseases  of  the  nervous  system.    Lond.,  1878.    p.  427. 


700  DISEASES   OF  THE  CERVICAL 

bodily  and  mental  exertion,  emotional  disturbances,  exposure  to 
draughts  of  cold  air,  changes  of  temperature,  and  gastric  irri- 
tation. The  attacks  not  unfrequently  cease  after  the  climacteric 
period  in  women,  and  after  the  fiftieth  year  of  age  in  men.  The 
symptoms  may  occasionally  disappear  either  spontaneously  or 
under  the  influence  of  remedies  in  young  persons  who  do  not 
manifest  a  hereditary  tendency  to  the  affection. 

Diagnosis. — In  forming  a  diagnosis  of  the  nature  of  a  head- 
ache, careful  examination  should  be  directed  to  the  external 
tissues  of  the  head  and  to  the  functions  of  the  brain,  peripheral 
nerves,  and  organs  of  special  sense.  The  state  of  the  digestive 
organs,  the  heart,  and  blood-vessels  often  affords  valuable 
information  with  respect  to  the  cause  of  a  headache,  while  a 
chemical  examination  of  the  urine  should  never  be  neglected.^ 
In  obstinate  headaches  lasting  for  years  an  ophthalmoscopic 
examination  should  always  be  made,  as  the  condition  of  the 
fundus  of  the  eye  may  indicate  the  existence  of  serious  cerebral 
disease,  as  tumour,  or  ursemic  or  other  poisoning.  The  circula- 
tory and  digestive  organs  should  be  carefully  examined,  and  the 
existence  or  absence  of  hereditary  predisposition  or  toxic 
influences  ascertained.  Valuable  information  may  sometimes 
be  obtained  by  percussing  the  skull. 

The  prognosis  varies  according  to  the  nature  of  the  cause  of 
the  headache,  and  except  in  the  case  of  organic  headache  it  is 
favourable  as  far  as  life  is  concerned. 

§  310.  Morbid  Anatomy  and  Physiology.  —  Inasmuch  as 
hemicrania  is  not  a  fatal  disease,  no  aid  need  be  expected  from 
morbid  anatomy  in  the  elucidation  of  its  pathology.  Pain  is 
the  predominant  symptom  of  migraine  to  the  patient,  but  the 
most  significant  symptoms  to  the  physician  are  those  connected 
with  the  vaso-motor  disturbances,  and  the  oculo-pupillary 
symptoms. 

In  hemicrania  sympathico-tonica  there  is  unilateral  tonic 
spasm  of  the  vessels  of  the  head,  such  as  may  be  caused  experi- 
mentally by  irritation  of  the  cervical  sympathetic  or  of  the 
corresponding  half  of  the  cilio-spinal  region  of  the  cord.  The 
other  symptoms  present,  such  as  increase  of  the  salivary  secre- 

»  Murchison.    The  Lancet.    Vol.  I.,  1874,  p.  538. 


PORTION  OF  THE  SYMPATHETIC.  701 

tion  and  dilatation  of  the  pupil  (spastic  mydriasis),  also  indicate 
irritation  of  the  cervical  sympathetic,  and  this  supposition  is 
much  strengthened  by  the  fact  that  the  region  of  the  superior 
and  middle  cervical  ganglia  of  the  sympathetic  and  the  spinous 
processes  of  the  lowest  cervical  and  uppermost  dorsal  vertebrae 
are  tender  to  pressure  during  the  attack,  and  sometimes  even 
during  the  intervals  of  pain  (Eulenburg).  The  symptoms  of 
hemicrania  angio-paralytica  are  characterised  by  an  opposite 
condition  of  the  vessels  to  that  which  is  present  in  the  spastic 
variety,  due  doubtless  to  a  diminished  action  of  the  cervical 
sympathetic  or  of  the  cilio-spinal  centre  of  the  affected  side. 
The  concomitant  oculo-pupillary  symptoms,  such  as  contraction 
of  the  pupil  (paralytic  myosis),  narrowing  of  the  palpebral  fissure, 
retraction  of  the  globe  of  the  eye,  occasional  ptosis,  strengthen 
this  conclusion,  inasmuch  as  they  are  the  well-known  effects 
produced  by  section  of  the  cervical  sympathetic  in  animals. 

Landois  believes  that  the  retardation  of  the  pulse  present 
during  the  attack  depends  upon  direct  irritation  of  the  medulla 
and  vagi.  Various  other  symptoms  show  that  the  vaso-motor 
centre  is  in  a  state  of  irritation.  The  icy  coldness  of  the  hands 
and  feet,  the  chilly  sensations  felt  over  the  whole  surface  of  the 
body,  the  suppression  of  perspiration  during  the  attack,  with  the 
exception  sometimes  of  the  affected  side  of  the  head,  the  con- 
tracted state  of  the  radial  artery,  and  the  increase  of  the  arterial 
tension,  may  be  explained  by  irritation  of  the  vaso- motor  centre. 
The  irritation  is  followed  by  a  corresponding  degree  of  exhaustion, 
and  then  the  contraction  of  the  peripheral  arteries  is  followed  by 
relaxation;  during  the  latter  stage  of  the  attack  there  is  an 
increased  secretion  of  saliva  and  urine,  and  watery  stools  may  be 
passed. 

With  regard  to  the  locality  of  the  pain  in  hemicrania,  many 
authors  regard  it  as  a  variety  of  supraorbital  neuralgia ;  but  the 
symptoms  of  the  two  affections  differ  from  each  other  in  so  many- 
ways  that  they  can  hardly  be  regarded  as  belonging  to  the  same 
category.  Romberg^  thought  that  the  pain  in  hemicrania  was 
due  to  hypersesthesia  of  the  brain,  and  consequently  he  called  it 
"  neuralgia  cerebralis,"  in  order  to  distinguish  it  from  peripheral 
neuralgia ;    and    although    this   view   is   not    accepted   in    its 

*  Komberg,    On  the  diseases  of  the  nervous  system.    Vol.  I.,  1853,  p.  177. 


702 


DISEASES   OF  THE   CERVICAL 


entirety,  the  opinion  is  gaining  ground  that  the  seat  of  the  pain 
is  within  and  not  without  the  cavity  of  the  cranium.  All  three 
divisions  of  the  trigeminus  send  branches  to  the  dura  mater. 
The  first  division  gives  off  the  nervus  tentorii  of  Arnold,  which 
passes  through  the  tentorium  to  the  sinuses  ;  the  second  division 
the  branch  which  runs  with  the  middle  meningeal  artery ;  and 
the  third  division  the  nervus  spinosus  of  Luschka  {Fig.  126). 

,  Numerous  nerves  are  found  in  the  pia  mater,  in  the  form  of 
plexuses  around  the  vessels,  and  some  of  these  extend  into  the 

Fig.  126. 


Fig.  126  (from  Henle's  Anatomie).  View  of  the  Base  of  the  Skull,  showing  the  Places 
of  Exit  of  the  Cranial  Nerves,  and  the  Sensory  Nerves  to  the  Dura  Mater . — The 
Koman  letters  indicate  the  Corresponding  Cranial  Nerves;  ro,  Nervus  Tentorii 
of  Arnold ;  rs.  Branch  from  the  Second  Division  of  the  Fifth  Nerve  accom- 
panying the  Middle  Meningeal  Artery ;  ri,  the  Nervus  Spinosus  of  Luschka 
derived  from  the  Third  Division  of  the  Nerve. 


PORTION   OF  THE   SYMPATHETIC.  703 

cortex  of  the  brain.  These  nerves  originate  partly  from  the 
vertebral  and  carotid  plexuses  of  the  sympathetic,  and  partly 
from  the  cerebral  nerves,  especially  the  trigeminus,  at  their 
points  of  exit  from  the  cranium.  Very  little  is  known  with 
regard  to  the  nerves  of  the  arachnoid.  It  is  supposed  by  some 
that  the  seat  of  pain  in  heraicrania  is  to  be  referred  to  the  intra- 
cranial and  meningeal  branches  of  the  trigeminus*  and  the  other 
nerves  which  accompany  the  blood-vessels,  and  not,  as  Romberg 
had  supposed,  to  the  cerebral  mass  itself. 

Du  Bois-Reymond^  thought  the  pain  was  produced  by  irrita- 
tion of  the  vascular  nerves,  due  to  a  tonic  spasm  of  the  muscular 
coat  of  the  vessels,  and  being  similar  to  the  pain  felt  in  cramp  of 
the  calf  or  in  tetanus,  and  in  the  smooth  muscles  of  the  uterus 
during  labour.  This  supposition  would  account  for  the  fact  that 
the  pain  increases  with  the  rise  in  arterial  tension,  and  that  each 
throb  of  pain  corresponds  to  each  pulsation  of  the  temporal  artery. 
Others  believe  that  the  temporary  anaemia  or  hypersemia  of  one- 
half  of  the  head  acts  as  a  source  of  irritation  to  some  or  all  of 
the  various  sensory  nerves  of  the  head,  those  of  the  skin,  peri- 
cranium, and  meninges.  It  is  now  recognised  that  either  anaemia 
or  hypersemia  of  the  peripheral  nerves  is  one  of  the  most  active 
causes  in  the  production  of  various  neuralgias,  such  as  proso- 
palgia and  sciatica ;  and  if  variations  in  the  vascular  supply  can 
induce  cutaneous  neuralgia,  it  is  thought  probable  that  a  similar 
result  may  follow  the  variations  of  blood  supply  to  the  head  in 
hemicrania. 

The  paroxysmal  character  of  hemicrania,  taken  along  with  the 
fact  that  it  occurs  in  the  members  of  families  manifesting  a 
neuropathic  tendency,  and  that  the  attack  is  often  preceded  by 
symptoms  such  as  scintillating  scotoma,  closely  resembling  an 
epileptic  aura,  has  led  some  pathologists  to  think  that  the  affec- 
tion is  closely  allied  to  genuine  epilepsy.  Dr.  Liveing'  insists 
strongly  upon  the  relationship  between  the  two  affections,  and 
attributes  the  attack  of  migraine  to  "  nerve  storms." 

'  See  Hasse.  Virchow's  Handbuch  der  speciellen  Pathol,  und  Therap.  Bd. 
IV.,  abth.  1,  1855,  p.  70. 

*  Du  Bois-Reymond.  *' Zur  Kenntniss  der  Hemikranie."  Arch.  fiirAnat.  und 
Physiol.,  1860,  p.  461. 

*  Liveing  (E.).  On  megrim,  sick-headache,  and  some  allied  disorders.  1873. 
p.^35  et  seq. 


704  DISEASES   OF  THE   CERVICAL 

Dr.  Hughlings  Jackson,^  however,  has  given  a  more  scientific 
expression  to  this  theory  by  attributing  the  headache  of  migraine, 
especially  the  form  which  is  associated  with  ocular  phenomena, 
to  a  discharging  lesion  from  the  cortex  of  the  posterior  lobes  or 
the  sensory  area  of  the  brain,  or  in  that  part  of  the  sensory  area 
which  is  the  anatomical  correlative  of  the  sensation  of  pain  in 
the  head ;  while  genuine  epilepsy  is  due  to  a  discharging  lesion 
of  the  motor  area  of  the  cortex.  But  during  the  attack  of 
migraine  the  nervous  discharge  does  not  remain  limited  to  the 
sensory  area,  since  some  is  directed  outwards  to  the  medulla 
oblongata  and  cilio-spinal  region  of  the  cord,  causing  irritation  or 
paralysis  of  some  of  these  centres,  and  giving  rise  to  the  vaso- 
motor and  oculo-pupillary  phenomena  present  during  the  attack. 
Attention  had  also  been  directed  by  Sieveking^  to  the  relation 
subsisting  between  certain  forms  of  headache  and  epilepsy,  and 
he  proposed  to  name  the  periodical  headaches  of  nervous  people 
cephalalgia  epileptica. 

§  311.  Treatment.  —  The  treatment  of  headache  may  be 
directed  against  either  the  cause  of  the  disease,  or  the  pain  itself 
as  a  local  symptom.  In  order  to  fulfil  the  first  indication,  the 
remedies  for  anaemia,  hysteria,  syphilis,  nervous  exhaustion,  and 
for  allaying  local  irritations,  must  be  employed  according  to  the 
nature  of  the  case. 

It  is  scarcely  possible  to  adopt  a  casual  treatment  in  the  case 
of  migraine,  inasmuch  as  so  little  is  known  of  the  circumstances 
which  concur  to  induce  an  attack.  The  ordinary  aperient  medi- 
cines which  are  generally  prescribed  for  the  cure  of  a  headache 
are  useless  in  migraine ;  but  Dr.  Wilks  thinks  that  the  act  of 
vomiting  occasionally  affords  relief.  The  vomiting,  however, 
does  not  appear  to  act  by  removing  indigestible  substances  from 
the  stomach.  The  effect  seems  to  be  produced  through  the 
nervous  system;  hence  this  remedy  cannot  be  regarded  as  one 
directed  against  the  cause  of  the  disease.  The  direct  treatment 
may  be  subdivided  into  that  which  is  appropriate  during  the 

'  Jackson  (Hughlings),  "  Case  illustrating  the  relation  between  certain  cases  of 
migraine  and  epilepsy."    The  Lancet,  Vol.  II.,  1875,  p.  244. 

*  Sieveking.     "  On  chronic  and  periodical  headache."    The  Medical  Times  and 
Gazette,  Vol.  II.,  1854,  p.  208,    See  also  Latham  (P.  W.).    •'  On  sick  headache."  - 
The  British  Medical  Journal,  Vol.  I.,  1873,  pp.  7  and  113. 


PORTION   OF  THE   SYMPATHETIC.  705 

intervals  in  order  to  prevent  the  attacks,  and  that  which  should 
be  adopted  with  the  view  of  removing  or  palliating  the  attacks 
themselves.  Although  the  following  remarks  are  particularly 
applicable  to  the  treatment  of  hemicrania,  yet  the  methods 
described  are  useful  in  other  forms  of  headache. 

The  preparations  of  iron,  especially  the  carbonate,  have  been 
strongly  advocated  by  Hutchinson,  Stokes,  and  others,  and  of 
their  utility  in  the  case  of  patients  who  are  of  weakly  and  ansemic 
constitution  there  can  be  no  doubt.  The  tolerable  regularity 
with  which  the  attack  recurs  has  led  to  the  employment  of  the 
so-called  antiperiodic  remedies  in  the  treatment  of  hemicrania. 
The  remedies  of  this  kind  which  have  been  employed  are  quinine, 
quinoidin,  salicin,  and  arsenic,  but  it  is  very  doubtful  whether  the 
recurrence  of  the  attacks  is  prevented,  or  the  paroxysms  are 
rendered  milder.  Strychnia,  nitrate  of  silver,  sulphate  of  nickel, 
bromide  of  potassium,  chloride  of  ammonium,  oil  of  turpentine, 
and  lupulin  are  other  remedies  which  have  been  employed,  but 
with  doubtful  success,  but  the  bromide  of  potassium  and  chloride 
of  ammonium  may  be  found  of  use  during  the  attack.  Chalybeate 
springs,  mud  and  sea  baths  have  each  been  found  useful  in  the 
treatment  of  hemicrania,  and  the  same  may  be  said  of  the  use 
of  hydropathy,  and  of  residence  in  lofty  mountain  regions ;  but 
all  these  measures  appear  to  influence  the  disease  by  improving 
the  general  health. 

In  the  treatment  of  the  attack  every  source  of  external 
irritation  should  be  removed,  the  room  should  be  moderately 
darkened,  and  all  noises  should  be  prevented.  In  the  ansemic 
form  the  patient  should  lie  flat  on  the  back  with  the  head  a 
little  raised,  but  in  the  hypersemic  form  the  patient  usually 
prefers  to  maintain  a  sitting  posture,  and  not  unfrequently  it  is 
more  grateful  to  rest  the  head  against  a  hard  substance.  When 
I  was  a  boy,  an  old  servant  in  our  family  suffered  from  severe 
periodical  headache,  which  prevented  her  from  sleeping,  and 
which,  so  far  as  I  can  remember,  had  all  the  characters  of  true 
migraine.  Her  remedy  was  to  place  a  stone  flag  on  her  pillow, 
and  by  resting  her  head  on  it  the  combined  hardness  and  cold- 
ness of  the  stone  seemed  to  enable  her  to  sleep,  and  next  morning 
she  woke  without  headache.  Firm  compression  of  the  head  by 
a  handkerchief  bound  round  it  is  an  old  remedy,  and  appears  to 

VOL.  I.  TT 


706  DISEASES   OF  THE   CERVICAL 

give  temporary  relief.  The  application  of  cold  may  be  of  use. 
It  may  be  applied  in  the  form  of  a  wet  cloth  bound  round  the 
temples,  an  evaporating  lotion,  or  an  ice-bag,  the  latter  of  which 
is  the  most  effectual.  Compression  of  the  carotid  in  the  neck 
will  suspend  the  throbbiog  pain  for  a  short  time,  but  the  effect 
is  very  transient,  inasmuch  as  the  blood  finds  its  way  to  the 
brain  through  other  channels. 

Although  quinine  when  given  as  an  antiperiodic  does  not 
appear  to  exert  much  influence  in  preventing  the  paroxysms  of 
pain,  yet  a  dose  of  from  five  to  fifteen  grains  given  once  or 
oftener  may  arrest  an  attack.  The  effect  appears  to  depend 
upon  an  action  on  the  vaso-motor  nerves,  since  it  has  been 
proved  experimentally  that  quinine  in  large  doses  contracts  the 
arterioles  and  raises  the  arterial  tension. 

Ergot  of  rye,^  given  in  half  drachm  doses  of  the  liquid  extract, 
has  also  been  found  exceedingly  useful  in  arresting  an  attack  of 
migraine ;  and  probably  acts  on  the  principle  of  contracting  the 
blood-vessels.  This  remedy  is  therefore  adapted  for  the  treat- 
ment of  the  angio-paralytic  variety. 

Dr.  Ringer  speaks  highly  of  cannabis  indica,  and  considers  it 
one  of  the  most  valuable  remedies  we  possess  for  sick  headache; 
he  thinks  that  it  is  most  useful  in  preventing  the  attacks,  not  in 
arresting  them  when  they  have  once  begun.  From  a  quarter  to 
half  of  a  grain  of  the  extract  or  ten  minims  of  the  tincture  may 
be  given  three  times  a  day.  It  may  be  combined  with  iron  or 
aloes.  Coffee  is  another  remedy  which  appears  to  act  by  stimu- 
lating the  vaso-motor  nerves.  It  may  be  given  in  the  form  of 
strong  infusion  of  the  ground  bean ;  but  it  is  much  more 
effectual  to  give  the  alkaloid  caffeine.  A  citrate  of  caffeine, 
which  is  merely  a  mechanical  mixture  of  caffeine  and  citric  acid, 
is  a  useful  mode  of  administration,  or  the  alkaloid  may  be  given 
subcutaneously.  The  citrate  of  caffeine  may  be  given  in  doses 
of  one  grain  every  hour  for  some  time  before  the  expected 
paroxysm.  Guarana  has  been  recommended  by  Dr.  Wilks,  and 
I  have  occasionally  found  it  useful,  but  as  its  active  principle 
is  identical  with  caffeine  it  is  probable  that  it  is  not  in  any  way 
superior  to  coffee  or  its  alkaloid. 

>  Woakes.    British  Medical  Journal.    Vol.  II.,  1868,  p.  360. 


PORTION   OF   THE  SYMPATHETIC.  707 

Nitrite  of  amyl  produces  a  beneficial  effect  in  the  sympathico- 
tonic form  of  the  disease.  Berger^  was  the  first  to  employ 
nitrite  of  amyl  inhalation  in  the  spastic  variety  of  hemicrania, 
and  the  pain  vanished  almost  instantly,  and  did  not  return 
that  day.  Other  observers  have  since  found  that  this  agent 
produces  a  temporary  palliation,  but  that  the  pain  returns 
in  most  instances  after  some  time.  Considerable  care  is  requisite 
in  inhaling  the  nitrite  of  amyl.  It  will  be  sufficient  to  inhale 
one  or  two  drops  on  a  handkerchief  at  first,  and  then  the  dose 
may  be  increased  to  three  or  five  drops,  and  if  necessary  the 
inhalation  may  be  repeated  after  a  short  time.  Meyer  recom- 
mends the  inhalation  of  carbonic  oxide  gas,  which  also  paralyses 
the  vaso-motor  nerves,  but  great  caution  is  necessary  in  using 
so  strong  a  poison.  Croton  chloral  hydrate  is  a  useful  remedy, 
and  although  it  does  not  always  arrest  the  paroxysm  of  migraine, 
it  is,  so  far  as  my  experience  goes,  the  most  generally  useful 
remedy  which  can  be  administered  during  the  attack.  I  always 
give  it  in  five  grain  doses  every  four  hours  till  relief  is  obtained ; 
but  it  may  be  administered  in  one  large  dose  of  fifteen  grains. 

Chloral  hydrate,  bromide  of  potassium,  and  chloride  of  am- 
monium may  also  be  given  during  the  attack,  the  latter  agent 
being  a  particularly  valuable  remedy  in  many  forms  of  head- 
ache. Dr.  Anstie  thought  the  best  means  of  arresting  a  sick 
headache  was  to  give  twenty  grains  of  chloral,  and  make  the 
patient  plunge  his  feet  into  very  hot  water  and  mustard  and 
breathe  the  steam.  Morphia  and  other  narcotics  may  be  em- 
ployed, but  their  effects  in  migraine  are  not  so  strikingly 
beneficial  as  in  neuralgia. 

The  constant  galvanic  current  is  one  of  the  most  powerful 
remedies  which  we  possess  in  hemicrania.  Holst^  was  the  first 
to  carry  out  a  rational  and  methodical  method  of  applying  it. 
According  to  this  method,  one  electrode,  which  is  made  long  and 
narrow  and  with  a  considerable  surface,  is  placed  at  the  inner 
edge  of  the  sterno-cleido-mastoid  muscle,  over  the  cervical  part 
of  the  sympathetic,,  and  the  other  is  placed  on  the  palm  of  the 
hand.     The  pole  on  the  n^ck  is  made  positive  in  hemicrania 

'  Berger.    Berl.  klin.  Wochenschr.    1867.    No.  2. 

*  See  Ealenburg.  Art.  "Vaso-motor  and  trophic  neuroses."  Ziemssen'a 
Cyclopaedia,  Vol.  XIV.,  1878,  p.  29. 


708  DISEASES  OF  THE  CERVICAL 

sympathico-tonica,  from  ten  to  fifteen  elements  being  used,  and 
the  current  is  suddenly  closed,  and  after  a  passage  of  two  or 
three  minutes  it  is  gradually  stopped.  The  pole  on  the  neck  is 
made  negative  in  hemicrania  angio-paralytica,  and  the  current  is 
not  only  suddenly  closed,  but  it  is  made  to  produce  powerful 
excitations  by  means  of  repeated  closures  and  openings,  or  in 
some  cases  by  reversals.  This  treatment  usually  brings  a  sense 
of  comfort  and  relief  in  a  very  short  time,  and  in  some  cases  it 
appears  to  produce  a  lengthening  of  the  intervals  between  the 
attacks.  Other  authors  prefer  to  pass  the  constant  current 
continuously  through  the  head. 

The  induced  current  has  been  recommended  by  Frommhold 
and  Fieber.  The  former  prefers  the  primary  induced  current  and 
applies  one  of  the  poles  high  up  the  back  of  the  neck  in  the 
median  line ;  and  the  other  upon  the  forehead,  or  over  the  super- 
ciliary arch.  Fieber  employs  the  "  electric  hand."  The  patient 
takes  one  conductor  in  his  hand,  and  the  operator  holds  the  other 
in  his  left  hand  while  he  applies  the  palm  of  his  right  hand 
firmly  upon  the  patient's  forehead,  which  is  previously  moistened. 
I  have  found  the  application  very  grateful  to  the  patient  during 
the  period  of  the  transmission  of  the  current,  but  have  not 
observed  it  produce  a  marked  effect  upon  the  duration  of  the 
attack.  In  dealing  with  the  various  forms  of  headache,  other  than 
hemicrania,  which  have  been  described,  the  treatment  must  be 
directed  against  the  cause  of  the  pain.  In  the  anaemic  form,  iron 
and  sustaining  diet ;  in  the  hypersemic,  saline  purgatives,  and  low 
diet ;  in  the  fibrile,  ice  to  the  head ;  in  the  hysterical,  iron  and 
moral  management  of  the  patient  are  the  means  of  treatment 
which  must  be  chiefly  relied  upon.  In  symptomatic  headache 
the  stomach  or  other  organ  which  is  the  source  of  irritation 
must  be  subjected  to  treatment;  in  gouty  headache  with  hepatic 
derangement  saline  purgatives  bring  relief;  and  in  the  neuralgi- 
form variety  saline  diuretics  and  agents  which  lower  the  arterial 
tension  are  indicated.  In  rheumatic  headache  salicylate  of  soda 
may  be  given,  but  iodide  of  potassium  is,  as  a  rule,  the  most 
effectual  remedy  for  such  cases.  In  syphilitic  headache  large 
doses  of  iodide  of  potassium  must  be  given  to  obtain  immediate 
relief,  and  it  depends  upon  circumstances  whether  this  should 
be  followed  up  by  a  mercurial  course.     In  obstinate  and  chronic 


PORTION  OF  THE  SYMPATHETIC.  709 

headaches  of  all  kinds  iodide  of  potassium  should  be  tried  ;  it 
often  affords  relief  in  organic  headaches  which  do  not  owe  their 
origin  to  syphilis.* 

(2)  Graves'  Disease  (Morbus  Basedowii,  Exophthalmic  Goitre). 

The  three  prominent  symptoms  of  Graves'  disease  are  palpi- 
tation, enlargement  of  the  thyroid  gland,  and  exophthalmos,  or 
undue  prominence  of  the  eyeballs,  these  being  usually  associated 
with  ansemia. 

The  disease  was  first  described  by  Parry'  in  1825,  but  the  first 
accurate  description  of  it  was  given  by  Graves^  in  1835,  and  by 
Basedow*  in  1840.  The  disease  has  since  been  investigated  by 
Stokes/  Charcot,®  v.  Graefe,^  and  others. 

§  312.  Etiology. — Sex  is  one  of  the  most  powerful  predis- 
posing causes  of  the  disease,  inasmuch  as  it  affects  the  female 
twice  as  often  as  the  male  sex. 

With  regard  to  age,  the  middle  period  of  life,  between  puberty 
and  the  climacteric  period,  is  affected  with  especial  frequency. 
The  disease  is  rare  in  childhood ;  yet  it  has  been  met  with  in  a 
girl  of  two  and  a  half  years.  Rosenberg  observed  it  in  one  of 
seven  years,  Solbrig^  in  a  boy  of  eight,  and  Trousseau^  in  one  of 
fourteen  years.  It  is  rare  beyond  the  climacteric  period,  yet 
Stokes  observed  the  disease  in  a  woman  of  sixty  years  of  age. 

Hereditary  predisposition  appears  to  exert  a  certain  amount 
of  influence  in  the  production  of  the  disease.  In  the  case  just 
mentioned,  as  having  been  related  by  Solbrig,  in  a  boy  of  eight, 

1  Moxon  (W.).  "On  the  treatment  of  headache  from  organic  intracranial 
disease."    The  Lancet,  Vol.  I.,  1875,  p.  750. 

*  Parry  (C.  H.).  Collections  from  the  unpublished  medical  writings  of.  Vol.  II., 
1825,  p.  110. 

^  See  Graves.  Clinical  lectures  on  the  practice  of  medicine,  edited  by  Neligan. 
Dublin,  1864.     p.  587. 

*  Basedow.  Casper's  Wochenschrift,  1840,  No.  13,  w.  14 ;  Abstr.  Schmidt's 
Jahrb.,  Vol.  XXIX.,  1841,  p.  335. 

°  Stokes.    Diseases  of  the  heart  and  the  aorta.    Dublin,  1853.    p.  278. 

^  Charcot.  "  Memoire  sur  une  affection  caracterisde  par  des  palpitations  du 
cceur  et  des  arteres,  la  tumefaction  de  la  glande  thsrreoide  et  une  double  exoph- 
thalmic, &c."    Gazette  M^dicale  de  Paris,  1856. 

^  V.  Graefe.    Arch,  fiir  Ophthalm,     Bd.  III.,  1857,  p.  285. 

^  Solbrig.  Zeitschrift  fiir  Psychiatrik,  1870-71,  p.  5  :  Abstr.  Canstatt's  Jahrb., 
Bd.  II.,  1870,  p.  15. 

*  Trousseau.    Gaz.  med.  de  Paris.    1862.    p.  474. 


710  DISEASES  OF   THE  CERVICAL 

the  mother,  and  in  the  case  of  a  girl  six  years  of  age,  reported 
by  Hawkes,'-  the  father,  were  said  to  have  suffered  from  the 
disease.  But  if  the  influence  of  direct  inheritance  is  doubtful, 
there  can  be  no  doubt  of  the  influence  exerted  by  a  neurotic 
predisposition,  inasmuch  as  the  disease  is  frequently  associated 
with  hysteria,  epilepsy,  and  mental  diseases. 

Chlorosis  and  anaemia^  with  their  associated  menstrual  disturb- 
ances have  been  supposed  to  act  as  powerful  factors  in  inducing 
the  disease ;  but  it  is  much  more  probable  that  the  ansemia  is 
a  result'  and  not  a  cause  of  the  affection. 

Injuries  of  the  head  have  been  known  to  have  produced  the 
disease,  and  it  is  frequently  caused  by  mental  excitement  and 
violent  fright  or  grief  Peter*  describes  the  case  of  a  woman, 
observed  by  Trousseau,  in  whom  the  disease  was  developed  in  the 
course  of  a  single  night  as  a  result  of  profound  grief  for  the  death 
of  her  father.  Her  nose  bled  profusely  during  the  whole  of  the 
night  referred  to.  Climate  may  possibly  exert  some  degree  of 
influence  in  the  production  of  the  affection.  Lebert^  states  that 
it  is  more  common  in  North  Germany  than  in  Switzerland  and 
France,  and  it  appears  to  be  more  frequent  in  England  than  on 
the  continent. 

§  313.  Symptoms. — The  disease  usually  develops  slowly  and 
gradually,  but  when  it  is  caused  by  emotional  disturbances,  or  by 
injuries,  it  may  begin  suddenly,  all  the  symptoms  appearing  in  a 
few  days.  In  a  few  cases  of  sudden  origin  the  disease  runs  an 
acute  course,  and  recovery  may  take  place  in  a  short  time.  In 
the  boy  observed  by  Solbrig  recovery  was  complete  in  ten  days. 

The  appearance  of  the  characteristic  phenomena  of  the  disease 
is  often  preceded  by  various  nervous  symptoms,  like  those  of 

»  Hawkes.  "On  enlargement  of  the  thyroid  gland  with  proptosis."  The 
Lancet,  Vol.  II.,  1861,  p.  130. 

"Begbie.  "Case  of  ansemic  palpitation, — enlargement  of  the  thyroid  glands 
and  eyeballs."    Edinburgh  Medical  Journal,  Vol.  LXXXII.,  1855,  Appendix  p.  33. 

^  See  Laycock  (T.).  "Clinical  Lectures  on  Exophthalmos,  &c.,"  The  Medical 
Times  and  Gazette,  Vol.  IL,  1864,  p.  323.  See  also  Aran.  "De  la  nature  et  du 
traitement  de  I'affection  comme  sous  le  nom  de  goitre  exophthalmique,"  Arch, 
g^ner.  de  med.,  Jan.,  1861,  p.  106. 

*  Peter,  "Notes  pour  servir  a  I'histoire  du  goitre  exophthalmique."  Gaz. 
hebd.,  1864,  p.  180. 

*  Lebert.  Die  Krankheiten  der  Schilddriise  und  ihre  Behandlung.  Breslau, 
1862.    p.  308. 


PORTION   OF  THE  SYMPATHETIC.  711 

hysteria;  the  patient  becomes  extremely  irritable  and  markedly 
changed  in  temper,  and  complains  of  flushings  of  the  face,  sen- 
sations of  fulness  in  the  head,  eyes,  and  throat,  and  of  violent 
throbbings  of  the  heart.  Palpitation  of  the  heart,  which  occurs 
at  first  only  at  intervals,  but  after  a  time  becomes  habitual,  and 
greatly  aggravated  by  emotion  or  exercise,  is,  indeed,  usually  the 
first  symptom  to  attract  the  patient's  attention.  On  physical 
examination  of  the  chest,  the  area  of  cardiac  dulness  may  be 
found  slightly  enlarged,  and  the  prsecordial  region  may  be  some- 
what prominent;  the  cardiac  pulsations  are  visible  over  a 
comparatively  wide  area^;  epigastric  pulsation  is  almost  always 
present ;  and  a  pulsation,  probably  of  arterial  origin,  is  frequently 
felt  over  the  right  lobe  of  the  liver ;  while  the  large  arteries  at 
the  root  of  the  neck  may  be  seen  to  beat  strongly.  On  auscul- 
tation the  cardiac  sounds  are  found  to  be  accentuated,  while  a 
■soft,  systolic,  blowing  murmur  is  generally  audible  at  the  base  of 
the  heart,  and  over  the  large  arteries,  more  especially  over  the 
carotid  and  thyroid  vessels.  The  pulse  is  always  accelerated, 
its  beats  averaging  from  90  to  120  per  minute  in  mild  cases,  and 
being  so  frequent  in  severe  cases  that  they  cannot  be  counted. 
It  is  said  that  digitalis  does  not  render  the  action  of  the  heart 
slower  in  this  affection.  When  the  symptoms  of  disordered 
circulation  have  lasted  for  a  considerable  time,  the  swelling  of 
the  thyroid  gland,  which  forms  the  second  great  feature  of  the 
disease,  becomes  developed.  The  swelling  appears  occasionally 
before  the  palpitation,  and  still  more  rarely  it  is  absent  altogether. 
The  swelling  of  the  gland  is  seldom  large,  and  the  size  of  the 
tumour  is  subject  to  frequent  changes,  being  increased  by 
emotional  disturbances,  pregnancy,  during  severe  attacks  of 
palpitation,  and  in  some  cases  during  each  systole  of  the  heart. 
The  gland  is  often  unequally  enlarged ;  the  swelling  is  limited 
in  some  cases  to  one  lateral  lobe,  while  in  other  cases  one  lobe 
is  more  swollen  than  the  other,  although  both  are  involved.  The 
swelling  is  soft  and  elastic ;  it  may  be  seen  to  pulsate ;  and,  when 
the  hand  is  laid  over  it,  a  distinct  thrill  is  felt,  which  has  led 
sometimes  to  its  being  mistaken  for  aneurism. 

Exophthalmos  makes  its  appearance  soon  after  the  swelling 
of  the  thyroid  gland,  and  occasionally  before  it,  and  still  more 

J  Trousseau.    Clinique  medicale  de  I'Hotel-Dieu.    Tome  II.,  1862,  p.  618. 


712  DISEASES   OF  THE   CERVICAL 

rarely  it  may  precede  both  the  palpitations  and  the  swelling. 
The  exophthalmos  is  almost  always  bilateral,  but  sometimes 
appears  earlier  in  one  eye  than  in  the  other,  and  it  is  often  not 
developed  to  the  same  degree  on  both  sides.  In  a  case  observed 
by  Dr.  Yeo^  the  enlargement  of  the  thyroid  and  the  exophthalmos 
presented  a  decidedly  unilateral  character,  the  goitre  being  on  the 
right,  and  the  exophthalmos  on  the  left  side.  In  some  few  cases 
the  exophthalmos  is  absent,  while  in  other  cases  it  forms  the 
only  symptom  of  the  disease. 

The  degree  of  exophthalmos  varies  greatly.  At  times  there  is 
only  a  slight  prominence  of  the  eyeball,  at  other  times  it  is  so 
excessive  that  no  part  of  the  globe  is  covered  by  the  eyelids,  and 
it  may  then,  during  exertion  or  straining  at  stool,  come  out  of 
the  orbit^  and  have  to  be  pushed  back  by  the  hand,^  When  the 
eyes  are  closed  to  their  utmost  there  may  be  a  space  of  a  quarter 
of  an  inch  or  more  between  the  lids,*  The  prominent  eyeball  ha& 
an  unusual  lustre,  caused  partly  by  the  prominence  of  the  globe, 
and  partly  by  the  fact  that  a  rim  of  the  sclerotic  coat  is  visible 
round  the  whole  of  the  cornea,  and  if  the  deformity  be  of  long 
standing,  there  is  either  partial  or  complete  loss  of  mobility  of 
the  eyeball,  which  gives  a  peculiar  stiffness  to  the  expression,  and 
a  "fierce"  appearance  to  the  patient.  This  fixed  staring  expres- 
sion has  been  described  in  graphic  language  by  Charlotte  Bronte 
in  Shirley: — "Certainly,  Miss  Mann,"  she  said,  "had  a  formidable 
eye  for  one  of  the  softer  sex ;  it  was  prominent,  and  showed  a  great 
deal  of  the  white,  and  looked  as  steadily,  as  unwinkingly,  at  you 
as  if  it  were  a  steel  ball  soldered  in  her  head." 

Yon  Graefe^  has  pointed  out  that  in  the  act  of  looking  up  or 
down  the  upper  lid  loses  its  power  of  moving  in  harmony  with 
the  eyeball,  a  phenomenon  which  must  be  regarded  as  a  very 
valuable  diagnostic  sign  of  the  disease.  When  the  eyeballs 
become  prominent  the  normal  relations  between  the  corneal 
sulci  and  the  margins  of  the  eyelids  are  lost,   and  it  may  be 

1  Yeo  (J.  B.).     The  British  Medical  Journal,  March  17th,  1877. 
'  O'Neill  (W.).     The  Lancet.    Vol.  I.,  1878,  p.  308. 

^Trousseau.  Lectures  on  Clinical  Medicine.  New  Syd.  Soc,  Vol,  I.,  1868, 
p.  543. 

*  Hutchinson  (J.).    The  Lancet.    Vol.  I,,  1872,  p.  538 

*  von  Graefe.  Deutsche  Klinik.,  1864,  p,  158,;  and  Berl.  klin,  Wochenschr, , 
1867,  p.  319. 


PORTION   OF  THE   SYMPATHETIC.  713 

supposed  that  "what  may  be  called  the  mechanical  movements 
of  the  eyelids  cease,  although  the  purely  muscular  movements 
may  still  be  retained  (§  229).  But  this  explanation  is  insuffi- 
cient, because  the  movements  of  the  lids,  as  has  been  pointed 
out  by  von  Graefe,  are  unaffected  in  the  exophthalmos  which 
results  from  tumours  of  the  orbit  and  other  causes. 

Disturbances  in  the  nutrition  of  the  globe  occur  in  consequence 
of  the  exophthalmos  and  the  defective  power  to  depress  the  upper 
lid.  In  ordinary  cases  the  conj  unctiva  alone  is  affected ;  it 
becomes  dry,  and  the  veins  are  distended,  while  it  is  very  liable 
to  be  attacked  by  inflammation.  In  severe  cases  the  nutrition 
of  the  cornea  suffers,  and  symptoms  like  those  of  neuro-paralytic 
ophthalmia  supervene. 

The  power  of  accommodation  is  usually  unaffected  in  this 
disease,  although  it  is  sometimes  weakened,  and  diplopia  may  be 
present  when  the  eyes  are  directed  to  near  objects,  owing  to  the 
deficient  mobility  of  the  globes.  Ophthalmoscopic  examination 
generally  shows  a  dilatation  and  increased  tortuosity  of  the 
retinal  veins,  along  with  visible  pulsation  in  the  arteries.  The 
pupil  is  usually  unaltered. 

Slight  elevation  of  the  temperature  of  the  body  can  generally 
be  detected  by  careful  measurement.  PauV  Teissier,^  Cheadle,^ 
and  Eulenburg*  have  found  an  elevation  varying  from  0"5°  to  1°  C; 
while  Charcot^  and  Dumont®  report  cases  in  which  the  tempera- 
ture was  normal.  Patients  often  suffer  from  a  sense  of  heat 
which  is  out  of  proportion  to  the  actual  elevation  of  temperature, 
and  it  is  sometimes  so  distressing  that  they  are  led  to  cast  off 
some  of  their  clothing.  This  sense  of  heat  is  often  accompanied 
by  an  increased  secretion  of  sweat.  Reynaud^  has  directed 
attention  to  the  connection  between  exophthalmic  goitre  and 
leucoderma;  in  five  cases  collected  by  him  patches  of  leucoderma 

'Paul.  "Zur  Basedowschen  Krankheit."  BerL  VHn,  Wochenschr.,  1865, 
p.  278. 

^  Teissier.     Canstatt's  Jahrb.    1864,  Bd.  IV.,  p.  173. 

3  Cheadle.     The  Lancet.    Vol.  I.,  1869,  p.  845. 

'*Eulenburg.  Art.  "Vaso-motor  and  trophic  neuroses."  Ziemssen's  Cyclopaedia, 
Vol.  XIV.,  1878,  p.  85. 

•Charcot.     Gaz.  med..,  1856,  p.  600 ;  Gaz.  hebd.,  1862,  No.  36. 
«  Dumont.     De  Morbe.  Basedowii  Inang.  Dissrt.    BerL,  1863.     p.  27. 
'  Eeynaud  (N.).     Vitiligo  et  goitre  exophthalmique.     Paris,  1875.     See  also 
Trousseau.    Clinique  Medicale,  Tome  II.,  1862,  p.  638. 


714  DISEASES   OF  THE   CERVICAL 

appeared  on  various  parts  of  the  body.  In  a  case  recorded  by 
Yeo^  a  considerable  proportion  of  the  hair  of  the  eyebrow  and 
eyelash  fell  out,  first  on  the  left  side,  which  was  the  one  most 
affected,  and  after  a  time  on  the  right  also,  as  the  eyeball  on 
that  side  became  prominent. 

Graves'  disease  is  sometimes  complicated,  as  already  noticed, 
with  other  severe  nervous  affections,  such  as  hysteria,  epilepsy, 
and  insanity  f  but,  in  the  absence  of  these  grave  disorders, 
patients  manifest  a  changeable  and  emotional  disposition,  being 
subject  to  alternations  of  excitement  and  depression. 

Patients  often  complain  of  severe  headache,  which  is  sometimes 
limited  to  one  side,  a  feeling  of  dizziness,  sleeplessness,  and 
weakness  of  thought  and  memory  along  with  inability  to  work. 
Usually  there  is  complete  anorexia,  occasional  vomiting,  and 
consequent  emaciation,  but  in  some  few  cases  the  appetite  is 
excessive. 

With  the  exception  of  the  few  cases  which  run  an  acute 
course,  the  duration  of  the  disease  is  always  very  protracted. 
Sometimes  complete  recovery  occurs  either  spontaneously  or  as 
the  result  of  treatment.  In  some  few  cases  pregnancy  appears 
to  have  had  a  favourable  influence  on  the  course  of  the  disease. 
Usually,  however,  the  symptoms  become  gradually  worse.  The 
increased  action  of  the  heart  leads  to  consecutive  enlargement 
of  the  organ,  with  its  usual  deleterious  effects.  At  other  times 
death  occurs  from  exhausting  marasmus  or  some  intercurrent 
disease,  such  as  oedema  of  the  lungs,  apoplectic  attacks,  tuber- 
culosis of  the  lungs,  or  valvular  disease  of  the  heart.  In  two 
cases  death  was  caused  by  progressive  gangrene  of  the  lower 
extremities  supervening  without  any  apparent  cause.^ 

Morbid  Anatomy. — The  parenchyma  of  the  thyroid  gland 
is  either  normal,  in  a  state  of  simple  hyperplasia,  or  may  contain 
cysts.  The  arteries  have  been  found  considerably  developed, 
and  the  veins  greatly  dilated.  A  considerable  development  of 
fat  is  generally  found  in  the  orbit  behind  the  globe,  and  the 
ophthalmic  artery  is  often  atheromatous,  while  advanced  fatty 

'  Yeo.     The  British  Medical  Journal,  March  17th,  1877. 

"^  Williams.  The  Lancet.  Vol.  II.,  1877,  p.  724.  And  Cane  (Leonard).  Ibid., 
p.  798. 

^  Foumier  et  Ollivier.  "  Observation  d'un  cas  de  goitre  exophthalmique,  termine 
par  des  gangrenes  multiples."    L'Union  M^dicale,  1868,  Nos.  8  and  9. 


PORTION   OF   THE   SYMPATHETIC.  715 

degeneration  of  the  ocular  muscles  has  been  met  with,  probably 
caused  by  disuse  and  stretching. 

Morbid  changes  have  been  found  by  various  authors  in  the 
cervical  sympathetic  and  its  ganglia,  while  other  competent 
observers  have  failed  to  detect  any  appreciable  alteration. 

The  principal  alterations  found  were  excess  of  connective 
tissue  and  a  diminution  of  the  nerve  elements,^  enlargement  of 
the  middle  and  lower  cervical  ganglia  and  disease  of  the  cord  of 
the  sympathetic,^  obliteration  of  the  lower  cervical  ganglia  of 
both  sides,^  atrophy  of  the  sympathetic  and  its  ganglia,*  in- 
creased size,  and  interstitial  thickening  of  the  upper  and  lower 
ganglia,^  and  ensheathing  of  both  cervical  sympathetics  in  dense 
connective  tissue.^ 

On  the  other  hand,  Wilks,'^  Paul,^  Fournier  and  Ollivier  assisted 
by  Ranvier,^  and  Rabejac  assisted  by  Bouvier,^"  found  nothing 
abnormal  in  the  cervical  ganglia  or  in  the  cervical,  thoracic,  or 
abdominal  cord  of  the  sympathetic.  In  two  cases  which  I 
examined  with  the  greatest  care,  using  a  large  number  of  stained 
preparations,  nothing  abnormal  could  be  detected  in  the  cervical 
sympathetic  and  its  ganglia. 

The  results  obtained  so  far  by  post-mortem  examination  are 
therefore  somewhat  doubtful ;  all  that  can  with  safety  be  con- 
cluded from  the  recorded  examinations  is  that  morbid  anatomy 
favours  the  view  that  the  anatomical  substratum  of  the  disease 
has  its  seat  in  the  cervical  sympathetic  and  its  ganglia,  supposing 
that  this  opinion  can  be  supported  by  other  evidence  of  an 
independent  character.  It  is  worthy  of  remark  that  in  the  few 
cases  where  positive  changes  were  found  in  the  sympathetic, 
the  inferior  cervical  ganglion  is  the  one  which  has  been  described 
as  being  chiefly  or  exclusively  affected. 

'  Peter.  "  Notes  pour  servir  a  I'histoire  du  goitre  exophthalmique."  Gaz. 
hebdom.,  1864,  p.  180. 

*  Keith  and  Beveridge.     Medical  Times  and  Gazette.    Vol.  II.,  1865,  p.  521. 

^  See  Moore.  "  Some  remarks  on  the  nature  and  treatment  of  pnlsating  thyroid 
gland  with  exophthalmos."  Dublin  Journal  of  Medical  Science,  Vol.  XI.,  1865, 
p.  344. 

*  Traube  and  Recklinghausen.     Deutsche  Klinik.    1863.    p.  286. 

«  Virchow.     Die  Krankhaften  Geschwulste.     Bd.  III.,  1867,  p.  81. 
«  GeigeL     Wiirzburg  Med.  Zeitschrift.    Bd.  VII.,  1866,  p.  84. 
'  Wilks.     Guy's  Hospital  Reports.     Bd.  XV.,  1870,  p.  17. 
^  Paul.     Berl.  klin.  Wochenschr.    1856. 
^  rournier  et  Ollivier.     Loc.  cit. 
'°  Rabejac.    Du  goitre  exophthalmique.     Th^se  Paris,  1869. 


716  DISEASES  OF  THE  CERVICAL 

§  314.  Morbid  Physiology. — The  theory  of  the  disease  has 
undergone  considerable  changes  in  the  course  of  time.  The 
disease  was  regarded  by  Basedow  and  other  early  observers  as 
being  the  result  of  a  morbid  crasis,  like  that  of  chlorosis,  while 
Stokes  thought  that  the  affection  was  due  to  disease  of  the 
heart.  Laycock  and  various  other  authors  regarded  the  affection 
'as  a  neurosis,  while  von  Graefe,*  Aran,^  Trousseau,^  and  others 
attributed  the  symptoms  to  disease  of  the  cervical  sympathetic, 
or  of  the  cervical  portion  of  the  spinal  cord  and  the  medulla 
oblongata. 

The  origin  of  the  swelling  of  the  thyroid  gland  may  be 
reo'arded  as  due  to  a  dilatation  of  the  arteries  and  veins  of  the 
thyroid  gland.  That  the  blood-vessels  of  the  thyroid  gland  are 
dilated  in  this  disease  has  been  proved  by  post-mortem  exami- 
nation, and  this  is  also  shown  to  be  the  case  during  life  by  the 
fact  that  the  small  branches  of  the  carotid  and  the  thyroid 
arteries  are  tortuous,  prominent,  and  may  be  seen  and  felt  to 
pulsate  strongly,  that  a  soft  blowing  sound  is  audible  over  them, 
and  that  the  tumour  becomes  alternately  diminished  or  increased 
in  size  according  to  the  force  of  the  pulsation  of  the  heart.  The 
soft  consistence  of  the  tumour  and  its  rapid  growth  point  to  the 
same  conclusion. 

Paralysis  of  the  vaso-motor  nerves  which  run  in  the  cervical 
sympathetic  is  supposed  to  be  the  cause  of  the  dilatation  of  the 
blood-vessels.  It  must  be  acknowledged,  however,  that  there  is 
no  experimental  evidence  as  yet  that  section  of  the  sympathetics 
can  produce  the  swelling  of  the  thyroid  gland,  Benedikt  thinks 
that  the  dilatation  of  the  vessels  is  due  to  irritation  of  the  dilator 
nerves,  which  run  in  the  sympathetics  and  not  to  paralysis  of 
the  vaso-motor,  but  the  evidence  for  this  theory  is  as  yet  in- 
sufficient. 

The  exophthalmos  is  probably  due  to  various  co-operating 
factors.  It  is  in  a  great  measure  dependent  upon  increased 
development  of  fat  in  the  cellular  tissue  of  the  orbit,  and  upon 
venous  hypersemia.  That  there  is  an  increase  in  the  fatty  tissue 
behind  the  eyeball  has  been  proved  by  a  series  of  autopsies,  and 

1  von  Graefe.    Arch  fur  Ophthal.    Bd.  III.,  1857,  p.  292. 

^  Aran.     Gaz.  hebd.     1860.    No.  49. 

3  Trousseau.    Gaz.  M^d,  de  Paris.    1862.    p.  474. 


PORTION   OF  THE  SYMPATHETIC.  717 

Id  one  of  two  cases  which  I  examined  this  was  certainly  the  case. 
But  contraction  of  the  muscles  of  Mueller,  induced  by  irritation 
of  the  cervical  sympathetic,  must  be  regarded  as  the  main  factor 
in  causing  protrusion  of  the  eyeballs,  and  the  action  of  these  is 
rendered  more  effective  by  the  fact  that  the  recti  muscles  are 
often  in  a  state  of  fatty  degeneration.  Various  reasons  might  be 
adduced  to  show  that  venous  hypersemia  of  the  vessels  of  the 
globe  and  orbit  exists  during  life,  but  it  will  suffice  to  mention 
that  Boddaert^  has  produced  a  considerable  exophthalmos  in 
rabbits  and  guinea-pigs,  which  lasted  some  days,  by  tying  the 
two  internal  and  external  jugular  veins,  and  dividing  both  cer- 
vical sympathetics. 

Irritation  of  the  accelerator  nerves  might  be  supposed  to  be 
the  cause  of  the  increased  cardiac  action,  but  then  it  is  necessary 
to  assume  a  paralysis  of  the  sympathetic  in  order  to  account  for 
the  swelling  of  the  thyroid  gland  and  the  exophthalmos,  and  it 
appears  a  somewhat  strained  interpretation  to  assume  that  one 
set  of  fibres  is  irritated  while  another  is  paralysed  by  the  same 
lesion.  But  affections  of  peripheral  nerves  sometimes  give  rise 
to  symptoms  of  paralysis  and  of  irritation  in  the  same  nerve. 
In  neuritis,  for  instance,  there  may  be  symptoms  of  irritation  in 
the  motor  fibres  along  with  diminished  sensibility,  and,  con- 
versely, hyperaesthesia  along  with  motor  paralysis.  It  is  not, 
therefore,  impossible  but  that  some  such  conditions  exist  in  the 
fibres  of  the  sympathetic,  although  few  will  accept  this  explana- 
tion as  satisfactory.  Benedikt  endeavoured  to  overcome  the 
difficulty  by  supposing  that  the  thyroid  swelling  was  caused  by 
active  irritation  of  dilator  nerves  which  run  in  the  sympathetic, 
but  this  supposition  encounters  many  difficulties.  It  is,  indeed, 
difficult  to  imagine  that  a  nerve  fibre  would  remain  in  a  per- 
manent state  of  irritation  for  many  years  without  paralysis 
supervening.  Friedreich,^  on  the  other  hand,  interprets  the 
palpitations  as  a  symptom  of  paralysis  of  vaso-motor  nerves. 
Paralysis  of  the  vaso-motor  nerves  of  the  sympathetic  is  followed, 
according  to  this  view,  by  dilatation  of  the  coronary  arteries, 
increased  flow  of  blood  to  the  muscular  walls  of  the  heart,  and 

*  Boddaert.  "  Note  sur  la  pathog^me  du  goitre  exophthalmique."  Bull  de  la 
Sec.  de  m^d.  de  Gand,  1872. 

^  Friedreich,  Traits  des  maladies  du  coeur,  traduit  par  Lorber  et  Doyon.  1873. 
p.  C59. 


718  DISEASES  OF  THE   CERVICAL 

increased  excitement  of  its  ganglia.  This  supposition  surmounts 
the  difficulty  of  supposing  that  a  permanent  lesion  gives  rise 
to  continuous  irritation  without  being  followed  by  subsequent 
paralysis,  but  considerable  difficulties  stand  in  the  way  of  both 
theories. 

Some  authors  have  endeavoured  to  explain  the  phenomena 
of  the  disease  on  the  supposition  that  the  cervical  part  of  the 
spinal  cord  and  medulla  oblongata  are  the  seat  of  morbid 
changes.  Exophthalmos  was  produced  by  Brown-Sdquard^  in 
animals  by  injury  to  the  restiform  body,  and  he  has  seen 
the  deformity  of  the  eye  transmitted  through  four  generations. 
Benedikt  also  places  the  lesion  in  the  medulla  oblongata.  Geigel 
assumes  that  the  lesions  in  the  affection  are  to  be  found  in 
the  cilio-spinal  region  of  the  cord,  and  thinks  that  one  of  the 
centres — the  oculo-pupillary — is  in  a  state  of  irritation,  and  the 
other — the  vaso-motor — is  in  a  state  of  paralysis,  These  theories 
are  mentioned  here  for  the  purpose  of  directing  the  attention  of 
future  workers  to  the  subject,  so  that  further  observations  may 
be  made  which  will  either  refute  or  confirm  them. 

Diagnosis  and  Prognosis. — At  the  beginning  of  the  disease 
the  diagnosis  presents  considerable  difficulties.  Provided  the 
exophthalmos  be  bilateral  and  accompanied  by  general  dis- 
turbance, the  existence  of  the  affection  may  be  inferred  even  in 
the  absence  of  one  of  the  other  two  leading  symptoms.  Of  the 
three  leading  symptoms  one  or  two  may  be  absent,  or  may 
disappear  temporarily.  The  most  valuable  of  the  subordinate 
symptoms  for  diagnostic  purposes  are  the  feeling  of  heat,  the 
elevation  of  temperature,  and  the  want  of  agreement  between 
the  movements  of  the  eyelid  and  globe.  The  cornea  being 
completely  surrounded  by  a  visible  ring  of  sclerotic  is  one 
of  the  most  valuable  indications  of  the  slighter  degrees  of 
exophthalmos. 

Cases  of  primary  enlargement  of  the  thyroid  gland  with  con- 
secutive irritation  of  the  sympathetics  may  closely  simulate 
Graves'  disease,  but  in  the  former  the  pupillary  and  vascular 
symptoms  are  generally  unilateral. 

The  prognosis  is  unfavourable,  although  some  cases  have  dis- 

•  Brown-S^quard.  "  On  the  hereditary  transmission  of  effects  of  certain  injuriea 
to  the  nervous  system."    The  Lancet,  YoL  I.,  1875,  p.  7. 


PORTION   OF  THE   S"S  MPATHETIC.  719 

appeared  spontaneously,  or  improved  under  medical  treatment. 
The  prognosis  is  more  favourable  when  the  general  health  of  the 
patient  is  good,  and  when  there  is  no  organic  disease  of  the  heart. 

§  315.  Treatment. — When  the  disease  was  regarded  as  being 
due  to  anemia,  quinine  and  iron  w^ere  the  remedies  usually 
employed  in  its  treatment ;  and  although  this  theory  is  now 
abandoned,  the  treatment  is  by  no  means  without  value. 

Remedies  which  depress  the  pulse  like  digitalis  and  veratrine 
have  been  prescribed  in  the  disease,  but  they  do  not  appear  to 
possess  any  value.  Iodine  is  said  to  diminish  the  swelling  of  the 
thyroid  gland,  but  to  increase  the  palpitations.  Belladonna  has 
been  employed  with  benefit. 

Galvanisation  of  the  cervical  sympathetics  has  been  used  of 
late  years  in  the  treatment  of  the  affection.  Von  Dusch  treated 
a  case  for  a  considerable  time  in  this  way,  with  the  result  of 
reducing  the  rate  of  the  pulse  from  130  to  70  or  64  beats,  and 
diminishing  the  exophthalmos.  Eulenburg^  speaks  favourably  of 
this  treatment.  The  method  he  adopted  was  to  apply  the  nega- 
tive pole  to  the  cervical  ganglia  of  each  side  alternately,  or  to 
both  at  once,  by  means  of  a  divided  electrode.  He  also  attacked 
the  swelled  neck  by  galvano-puncture,  but  only  doubtful  results 
were  obtained.  Chovstek,  Meyer,  and  Leube  each  obtained 
favourable  results  by  galvanisation  of  the  cervical  sympathetics. 

The  habits  of  the  patient  should  be  carefully  regulated ;  all 
fatigue,  venereal  excess,  and  mental  excitement  should  be  avoided. 
The  diet  should  be  mild  and  nutritious,  chiefly  composed  of  milk 
and  vegetables,  and  the  patient  should  avoid  the  use  of  alcoholic 
beverages,  and  even  tea  and  coffee  except  in  very  moderate 
quantity.  A  large  portion  of  the  day  should  be  spent  in  the 
open  air,  especially  in  the  country,  or  in  mountain  health  resorts 
of  moderate  elevation.  Chalybeate  mineral  springs,  such  as  those 
of  Franzensbad,  Pyrmont,  Schwalbach,  and  Flitwick,  are  of  con- 
siderable value  in  the  treatment  of  the  disease.  For  the  exoph- 
thalmos von  Graefe  recommended  painting  with  tincture  of 
iodine,  or  friction  with  iodide  of  potassium  ointment  over  the 
eyebrows  and  upper  lids,  compresses,  local  electrisation,  and  in 
severe  cases  tarsorrhaphia  as  a  protection  against  malignant 
affections  of  the  cornea. 


720  DISEASES  OF  THE  CERVICAL 

(3)  Unhateral  Progressive  Atrophy  of  the  Face  (Hemiatrophia 
Facialis  Progressiva). 

Unilateral  progressive  atrophy  of  the  face  is  characterised  by 
a  slow  and  gradual  loss  of  substance  in  one  side  of  the  face, 
which  usually  begins  in  the  external  soft  parts  and  passes  suc- 
cessively to  the  deeper  tissues. 

History. — The  disease  was  observed  by  Parry^  in  1825,  but  it 
was  first  carefully  studied  and  described  by  Romberg'  and  his 
scholars — Bergson,^  Schott,*  and  Heuter  and  Axmann,^  Cases 
of  the  disease  were  afterwards  reported  by  Virchow,^  Samuel,^ 
Guttmann,^  Moritz  Meyer,^  and  Moore.^°  Although  the  disease 
was  described  by  Lasegne,"  Ball/^  and  Ollivier,^^  yet  Bitot ^*  ob- 
served the  first  case  of  the  affection  in  France  in  1862,  and 
another  in  1866  ;  and  his  pupil,  Lande,^^  based  upon  these  his 
inaugural  dissertation  in  1869,  and  his  very  able  monograph 
published  in  1870. 

§  316.  Etiology. — The  disease  has  hitherto  been  observed  about 
twice  as  often  in  women  as  in  men,  and  it  appears  to  have  a 
special  predilection  for  the  left  side  of  the  face.  In  thirteen 
cases  collected  by  Eulenburg  the  affection  began  before  thirty 

*  Parry  (C.  H. ).    Collection  from  the  unpublished  writings.  Vol.  I.,  1825,  p.  478. 

*  Romberg  und  Henoch.     Klinische  Engebnisse.     Berlin,  1846.    p.  75. 

^  Bergson.  Prosopodysmorphi^  sive  novS,  atrophia  facialis  specie.  Diss,  inang. 
Berl,  1837. 

*  Schott.  Atrophia  singularium  partium  corporis,  quae  sine  causa  cognita  ap- 
paret,  trophoneurosis  est ;  Diss.  Marburg,  1851 . 

*  Heuter.     Singularis  cujusdam  atrophise  casus  nonnulli.     Diss.  Marburg,  1848. 
°  Virchow.     Handbuch  der  speciellen  Path,  und  Therapie.     Bd.  I.,  1854,  p.  321; 

and  Deutsche  Klinik.,  1859,  p.  336. 

^  Samuel.    Die  trophischen  nerven.    Leipzig,  1860. 

^  Guttmann.  "  Ueber  einsitigen  Gesichtsatropbie  durch  den  Einfluss  trophi- 
scher  nerven."    Arch.  f.  Psychiat.,  Bd.  L,  1868,  p.  173. 

«  Meyer  (Moritz).  Sitzung  der  Berlin  med.  Gesellschaft.  No.  17,  1869 ;  Berl. 
klin.  Wochenschr.,  10  Janvier,  1870,  p.  23. 

'"Moore.  "Case  of  unilaterar atrophy  of  the  face."  Dublin  Journal  of  the 
Medical  Sciences,  Vol.  XLII.,  1852,  p.  245. 

^ '  Lasegne.  Atrophic  partielle  de  la  face  (trophon^urose  de  Romberg).  Arch. 
g6n.  de  m6d.,  4^  Se'rie,  Tome  XXIX.,  1852,  p.  71. 

'''Ball  (Benj.).  Dictionnaire  encyclopedia  des  sciences  m^dicales.  Article, 
"Atrophic."    Tome  VII.,  1867,  p.  188. 

'^  Ollivier  (Aug.).    Des  atrophies  musculaires.    Thfese  de  Paris,  1869. 

'*  See  Gintrac  (Henri).  Dictionnaire  de  medicine  pratiques.  Tome  XIV.,  1871, 
p.  379. 

'*Lande  (L.).  Esaai  sur  I'aplasie  lamineuse  progressive.  These  Paris,  1869;  et 
"  Sur  une  forme  d'atrophie  partielle  de  la  face,"    Arch,  g^ner.  de  mdd.,  Mars,  1870. 


PORTION   OF  THE   SYMPATHETIC.  721 

years  of  age,  the  majority  appearing  between  ten  and  fifteen 
years,  but  in  a  few  instances  the  affection  began  as  early  as 
between  two  and  three  years  of  age. 

In  a  few  cases  the  outbreak  of  the  disease  has  been  preceded 
by  scarlatina,  measles,  whooping  cough,  or  a  local  herpetic 
eruption,  and  in  other  cases  its  origin  has  been  attributed  to 
exposure  to  cold.  Toothache,  and  tearing  pains  in  the  head, 
and  the  superior  maxillary  region  of  the  affected  side,  have 
sometimes  been  complained  of  before  the  commencement  of  the 
atrophy.  In  a  case  published  by  Meyer,  the  patient  suffered  from 
epileptic  fits,  and  some  of  these  were  limited  to  the  portion  of 
the  face  which  afterwards  became  atrophied.  In  Brunner's  case 
epileptic  attacks  supervened  for  the  first  time  during  pregnancy, 
and  continued  a  year  before  the  appearance  of  facial  atrophy. 
The  disease  was  preceded  in  Parry's  case  by  left  hemiplegia  ;  and 
in  the  case  observed  by  Heuter  and  Axmann  the  patient  suffered, 
for  many  years  before  the  atrophy  began,  from  irregular  spastic 
contractions  of  the  masticatory  muscles,  along  with  some  degree 
of  hypersesthesia  of  the  left  side  of  the  face,  that  being  the  side 
which  was  afterwards  the  subject  of  atrophy.  Anjel  also  observed 
a  case  in  which  spasms,  hypersesthesia,  and  parsesthesise  in  the 
left  half  of  the  face  preceded  the  atrophy. 

§  317.  Symiotoms. — The  first  symptom  to  attract  notice  is  a 
peculiar  discolouration  of  circumscribed  areas  of  the  skin.  A 
white  spot,  which  is  slightly  depressed  and  gradually  spreads, 
appears  on  one  side  of  the  face.  Several  of  these  spots  may 
appear,  either  simultaneously  or  in  succession,  and  after  a  time 
they  coalesce  so  as  to  form  a  patch  of  considerable  size.  The 
white  colour  may  be  transitory,  and  the  affected  area  may  assume 
a  yellowish  or  brownish  tint,  such  as  is  frequently  observed  in 
cicatrices  after  burns.  These  spots  soon  become  the  seat  of 
a  marked  atrophy,  the  skin  becomes  thin  and  emaciated,  and 
the  subcutaneous  fat  disappears  so  that  the  side  of  the  face 
becomes  deformed  by  pits  of  greater  or  lesser  size  and  depth. 
The  fatty  tissue  behind  the  globe  often  disappears,  so  that 
the  eye  on  the  affected  side  falls  back  into  the  orbit  and  thus 
appears  more  sunk  and  smaller,  whilst  the  palpebral  aperture 
is  narrower  than  on  the  sound  side.  The  beard,  eyelashes, 
VOL.  I.  UU 


722  DISEASES  OF  THE  CERVICAL 

and  even  the  hair  of  the  head  on  the  affected  side  usually 
undergo  structural  changes,  and  these  may  sometimes  pre- 
cede the  formation  of  the  cutaneous  spots  and  depressions. 
The  hair  at  times  turns  perfectly  white,  at  other  times  it 
falls  out,  or  its  growth  is  more  or  less  interfered  with,  while 
in  a  few  cases  streaks  only  of  the  hair  of  the  head  or  of  the 
eyelids  and  eyebrow  are  discoloured.  The  secretion  of  the 
sebaceous  follicles  is  arrested,  but  the  functions  of  the  sweat 
glands  appear  to  be  normally  performed.  The  involuntary 
muscular  fibres  of  the  skin  give  a  normal  reaction  to  electrical 
stimulation.  In  advanced  cases  the  affected  skin  feels  irregular 
and  atrophied,  and  it  may  assume  the  form  of  a  cicatrix,  but  does 
not  become  adherent  to  the  underlying  structures.  The  cuta- 
neous sensibility  is  not  usually  affected,  but  in  one  case  it 
was  diminished,  while  in  other  cases  hypersesthesia  has  been 
observed.  Abnormal  sensations  have  often  been  complained  of 
in  the  atrophied  portions  of  skin.  Neuralgic  attacks  have 
been  experienced  on  the  affected  side  during  the  progress  of 
the  disease,  but  pain  is  not  an  invariable  symptom.  The 
muscles  on  the  affected  side  are,  as  a  rule,  unaffected,  and 
give  normal  reactions  to  electrical  stimulation.  In  some  cases 
the  muscles  were  diminished  in  bulk,  fibrillary  twitchings  were 
observed,  and  the  face  was  somewhat  drawn  to  the  atrophied 
side. 

In  a  case  observed  by  Eulenburg  and  Guttmann,  the  masti- 
catory muscles  on  the  affected  side  were  distinctly  emaciated, 
and  the  movements  of  mastication  on  that  side  were  weakened. 
In  some  cases  decided  asymmetry  in  the  contour  of  the  upper 
lip  has  been  observed,  owing  to  atrophy  of  one-half  of  the 
orbicularis,  while  in  other  cases  the  half  of  the  tongue  on  the 
affected  side  was  diminished  in  bulk,  and  deviated  to  a  slight 
extent  to  the  affected  side  on  protrusion,^  but  the  muscles  on  the 
affected  side  of  the  organ  give  normal  electrical  reactions.^  The 
vault  of  the  palate,  the  velum,  and  the  uvula  have  also  at  times 
been  involved  in  the  atrophy,^  but  deglutition   has   not  been 

•  See  Hammond  (W.  A.),  The  Journal  of  Nervous  and  Mental  Diseases. 
New  York.    March,  1880, 

■"  See  MuUer  (Franz),     Centralbl.  f,  Nervenheilkunde.    Bd,  IV.,  1881,  p.  254. 

'  Baerwinkel  (Fr.),  "  Neuropathologische  Beitrage,"  Deutsches  Arch.  f.  klin. 
med,,  Bd,  XII,,  1874,  p,  607. 


PORTION   OF  THE  SYMPATHETIC. 


723 


interfered  with  in  any  recorded  case.   In  one  case  tLe  pronuncia- 
tion of  the  letter  "  r  "  was  somewhat  impeded.* 

The  annexed  figure,  borrowed  from  Romberg,  represents  the 
case  of  an  unmarried  woman,  aged  twenty-eight  years,  who  had 
suffered  from  this  affection.  The  left  side  of  her  face  had 
gradually  atrophied  as  the  result  of  extensive  suppuration  on 
the  left  side  of  the  neck,  which  burst  through  the  tonsil. 
Every  feature,  including  the  brow,  eye,  nostril,  lips,  cheek,  and 

Fig.  127. 


chin,  as  well  as  the  left  half  of  the  tongue  and  left  palatine 
arch,  was  smaller  than  those  on  the  opposite  side. 

The  large  arteries  of  the  face  are,  as  a  rule,  unaltered  in  size, 
and  the  tone  of  the  small  arteries  is  retained  or  even  increased. 
The  atrophied  parts  are  generally  capable  of  blushing,  and  they 
also  redden  under  local  electrical  excitation.  The  temperature 
is  the  same  on  both  sides. 

The  hones  of  the  face  have  been  found  distinctly  diminished 
in  volume.  Atrophy  of  the  upper  and  lower  maxillary  and 
malar  bones,  and  even  of  the  cartilages  of  the  nose  have  been 
observed,  and  the  teeth  may  undergo  consecutive  alterations. 

1  Eulenburg.    Ziemssen's  Cyclopeedia.    Vol.  XIV.,  1878,  p.  64. 


724  DISEASES   OF  THE   CERVICAL 

Virchow^  believes  that  the  bones  of  the  face  are  so  much  the 
less  affected  the  more  fully  developed  they  are  before  the  disease 
begins,  and  in  a  case  recorded  by  Kiister,^  in  which  the  first 
symptoms  were  noticed  when  the  patient  was  twenty-eight  years 
of  age,  the  corresponding  bones  of  the  two  sides  of  the  face  gave 
equal  measurements,  although  the  other  phenomena  of  the 
disease  were  particularly  well  marked. 

§  318.  Morbid  Anatomy  and  Physiology. — The  majority  of 
authors  regard  the  disease  as  of  nervous  origin,  although  Lande 
and  a  few  others  believe  it  to  be  a  primary  atrophy  of  the 
fatty  tissue  and  of  the  cells  and  fibrils  of  the  connective  tissue, 
leaving  only  the  elastic  fibres  unaltered. 

The  nervous  theory  of  the  origin  of  the  disease  has  assumed 
two  chief  forms,  some  pathologists  attributing  the  affection  to 
disease  of  the  vaso-motor,  and  others  to  disease  of  the  trophic 
fibres  of  the  trigeminus.  Bergson  was  the  first  to  attribute  the 
disease  to  a  primary  affection  of  the  vaso-motor  nerves.  In  the 
case  described  by  him,  the  carotid  artery  on  the  affected  side 
pulsated  less  strongly  than  that  on  the  sound  side,  and  he 
thought  that  the  atrophy  was  due  to  the  diminution  of  the 
calibre  of  the  artery.  But  this  theory  is  manifestly  inadequate, 
since  neither  continual  irritation  nor  paralysis  of  the  vaso-motor 
nerves  gives  rise  to  symptoms  at  all  comparable  with  those  of 
progressive  paralysis  of  the  face. 

Romberg  classified  this  affection  as  a  trophoneurosis,  but  the 
relation  of  the  disease  to  the  trophic  system  of  nerves  was  after- 
wards more  fully  developed  by  Samuel.  Atrophy  of  the  muscles 
supplied  by  the  motor  portion  of  the  fifth  has  been  observed  in 
some  cases  of  the  disease,  a  circumstance  which  strongly  points 
to  the  influence  of  the  fifth  in  the  production  of  the  affection. 
Muscular  atrophy,  however,  is  always  a  subordinate  symptom  in 
comparison  with  the  nutritive  disturbances  of  the  integuments, 
the  former  being  in  many  cases  completely  absent. 

Experiments  have  shown  that  the  vaso-motor  and  trophic 
fibres  of  the  face  run  in  the  sympathetic  before  passing  to  the 

*  Virchow.  "Ueber  nenrotische  atrophie."  Berl.  klin.  Wochenschr.,  18S0,  p.  409. 
^  Kiister.    "  Vorstellung  eines  Falles  von  halbseitiger  Gesichtsatrophie."  Neuro- 
logische  Centralb].,  Bd.  I.,  1882,  p.  31. 


PORTION   OF   THE  SYMPATHETIC.  725 

trigeminus,  hence  it  is  possible  that  this  disease  may  at  times 
be  caused  by  lesion  of  the  sympathetic,  Seeligmliller  described 
two  cases  in  which  the  atrophy  appeared  to  be  due  to  injury 
of  the  sympathetic.  In  the  first  case  the  cord  of  the  sym- 
pathetic and  the  brachial  plexus  in  a  child  were  injured  by 
fracture  of  the  clavicle  and  neck  of  the  scapula,  and  myosis  was 
combined  with  decided  atrophy  of  the  side  of  the  face.  The 
second  case  was  one  of  gunshot  wound  of  the  left  sympathetic 
and  a  part  of  the  brachial  plexus,  and  in  addition  to  the  usual 
oculo-pupillary  symptoms  there  was  distinct  emaciation  and 
flattening  of  the  left  cheek.  In  a  case  observed  by  Brunner 
the  symptoms  corresponded  to  the  usual  results  of  experimental 
irritation  of  the  divided  cervical  sympathetic.  The  symptoms 
were  dilatation  and  deficient  reaction  of  the  pupil,  widening  of 
the  palpebral  fissure,  exophthalmos,  deficiency  of  the  lachrymal 
secretion  and  of  the  secretion  of  mucus  and  sweat,  and  lowering 
of  the  temperature  of  the  whole  left  side  of  the  face.  The  left 
superior  ganglion  of  the  sympathetic  was  tender  on  pressure. 
Brunner^  thinks  that  a  continued  irritation  of  the  sympathetic 
produced  a  persistent  spasm  of  the  blood-vessels,  and  that  this 
led  to  a  gradual  atrophy  of  the  left  side  of  the  face.  It  is  not 
improbable  but  that  the  lesion  may,  in  some  cases  at  least,  be 
situated  in  the  medulla  oblongata.^ 

§  319.  Diagnosis  and  Prognosis. — The  disease  may  be  mis- 
taken for  congenital  asymmetry  of  the  two  halves  of  the  face, 
but  in  the  latter  condition  the  characteristic  atrophy  of  the  skin 
and  subcutaneous  tissues  are  wanting.  In  torticollis  and  scoliosis 
of  the  vertebral  column,  the  side  of  the  face  corresponding  to 
the  convexity  of  the  main  curve  is  often  smaller  than  the  other 
side.  Arrest  of  development  of  one  side  of  the  face  may  be 
caused  by  traumatic  injury  received  during  youth,  but  neither 
the  colour  of  the  face  nor  of  the  hair  is  altered.  Hypertrophy 
of  the  opposite  side  of  the  face  can  only  be  mistaken  for  atrophy 
by  carelessness  of  observation.     Certain  cutaneous  affections,  as 

'  Brunner.  "Zur  casuistik  du  Pathologie  des Sympathicus. "  Petersburgermed. 
Zeitschrift,  N.F.     Bd.  II.,  1871,  p.  260. 

"See  Miiller  (Franz).  "  Hemiatrophia  facialis  progressiva."  Ceutralbl.  f. 
Nervenh.,  Bd.  IV.,  1881,  p.  255. 


726  CEEVICAL  PORTION   OF  THE  "SYMPATHETIC. 

vitiligo  and  tinea  decalvans,  may  be  mistaken  for  the  early  stage 
of  the  affection.  In  vitiligo  there  is  the  same  white  discoloura- 
tion of  the  integument,  the  cicatricial  appearance  of  the  skin, 
greyness  and  falling  out  of  the  hair;  but  the  loss  of  volume, 
which  is  the  special  characteristic  of  progressive  unilateral 
atrophy,  is  absent.  In  tinea  decalvans  the  disease  first  appears 
in  regular  circular  spots,  it  is  contagious,  fungi  can  be  detected, 
and  the  hairs  fall  out  without  previous  loss  of  colour,  and  the 
loss  of  hair  is  preceded  by  inflammatory  symptoms  and  oedema 
of  the  skin. 

The  disease  is  always  slow  and  protracted,  and  its  course  is 
usually  steadily  progressive,  although  a  brief  pause  appears  in 
some  cases.  The  general  health  is  not  interfered  with,  but  so 
far  as  recovery  is  concerned  the  prognosis  is  very  unfavourable. 

§  320.  Treatment — Various  remedies  have  been  employed, 
but  none  of  them  have  hitherto  proved  successful.  Electrical 
treatment  has  been  adopted  in  almost  all  the  reported  cases. 
The  use  of  the  constant  current  is  said  to  have  produced  in 
some  cases  an  improvement  in  the  nutrition  and  colour  of  the 
skin,  and  under  its  use  the  power  to  blush  returned.  In  a  case 
observed  by  Eulenburg  and  Guttmann,  the  local  application  of 
the  faradic  and  galvanic  currents  for  several  months  and  the 
galvanisation  of  the  sympathetics  did  not  lead  to  any  permanent 
benefit,  though  local  galvanisation  produced  a  reddening  of  the 
affected  side  of  the  face,  which  continued  for  several  hours  after 
each  application. 


727 


CHAPTER  III. 


DISEASES   OF   THE   THORAGIC   PORTION   OF   THE 
SYMPATHETIC. 

AXGIXA    PECTORIS. 

Angina  pectoris  consists  of  paroxysms  of  pain  in  the  prsecor- 
dial  region,  usually  radiating  over  the  left  side  of  the  thorax  and 
down  the  left  arm,  and  associated  with  a  peculiar  sensation  of 
constriction  and  intense  anxiety.  It  must  be  remembered  that 
every  form  of  angina  pectoris  is  not  due  to  disease  of  the  sym- 
pathetic nerves;  but,  as  the  different  varieties  of  the  affection 
are  allied  clinically,  it  is  deemed  better  to  describe  all  of  them 
in  this  place. 

§  321.  Etiology. — Angina  pectoris  is  sometimes  a  mere  symp- 
tom of  grave  organic  affection,  such  as  aortic  disease,  fatty  degene- 
ration of  the  heart,  and  ossification  of  the  coronary  arteries,  but 
such  cases  cannot  be  discussed  here.  The  only  cases  which  will 
be  mentioned  here  are  those  in  which  the  angina  is  a  pure 
neurosis,  unaccompanied  by  any  perceptible  organic  change  in 
the  heart.  The  causes  of  the  neurotic  affection  are  singularly 
obscure.  Hereditary  predisposition  can  be  traced  in  many  cases 
of  angina,  and  it  is  frequently  found  in  members  of  families  who 
manifest  a  tendency  to  other  neurotic  diseases,  such  as  hysteria, 
insanity,  and  epilepsy.  Attacks  of  angina  may  form  a  symptom 
of  hysteria,  precede  or  alternate  with  an  attack  of  epilepsy,  or 
constitute  an  intercurrent  symptom  of  chronic  mental  disease. 

The  disease  occurs  most  frequently  in  advanced  age,  but  it  is 
probable  that  the  proportionate  frequency  with  which  it  is  sup- 
posed to  occur  in  old  age  depends  upon  the  angina  symptomatic 


728  DISEASES   OF  THE  THOKACIC 

of  organic  cardiac  disease  being  mistaken  for  true  neurotic  angina 
pectoris.  The  male  sex  is  much  more  liable  to  be  attacked  than 
the  female,  probably  because  the  former  is  more  exposed  to  the 
exciting  causes  than  the  latter. 

The  first  of  the  exciting  causes  of  the  disease  which  deserves 
mention  is  exposure  to  cold.  Excessive  smoking  of  tobacco 
appears  undoubtedly  to  induce  attacks  of  the  disease.  Beau 
describes  eight  cases  in  which  the  attacks  ceased  when  smoking 
was  stopped,  and  returned  on  the  practice  being  resumed,  and 
similiar  cases  are  recorded  by  other  authors.  Other  exciting 
causes  are  certain  morbid  conditions  of  the  thoracic  organs, 
which  involve  the  nerves  of  the  cardiac  plexus,  and  morbid  con- 
ditions of  the  abdominal  regions,  which  probably  act  by  reflex 
irritation. 

§  322.  Symptoms. — Angina  pectoris  occurs  in  paroxysms, 
which  are  separated  from  one  another  by  longer  or  shorter  inter- 
vals. The  attack  begins  suddenly.  Pain  is  felt  at  the  lower 
part  of  the  sternum  and  shoots  over  the  left  side  of  the  chest 
and  neck,  or  along  the  sternum  and  down  the  left  arm  or  both 
arms.  When  both  arms  are  implicated,  the  pain  is  aways  more 
pronounced  on  the  left  side  of  the  chest  and  left  arm  than  on 
the  corresponding  parts  of  the  right  side.  The  character  of  the 
pain  is  described  as  shooting,  tearing,  aching,  sickening,  or 
burning,  and  it  is  often  said  to  be  indescribable.  A  feeling  of 
oppression  or  constriction  is  felt  across  the  chest  as  if  it  were 
being  forcibly  compressed  and  could  not  be  expanded.  This 
feeling  is  accompanied  by  a  sense  of  suffocation  and  inability  to 
breathe,  although  the  patient  is  only  prevented  from  breathing 
by  the  pain,  and  not  from  any  mechanical  interference  with  the 
act  of  respiration.  The  pain  is  accompanied  by  a  feeling  of  great 
anxiety  and  dread  of  impending  death,  the  face  becomes  pale 
and  covered  with  sweat,  and  the  expression  is  one  of  great  alarm 
and  fear.  The  beats  of  the  heart  are  usually  feeble  and  inter- 
mittent; while  at  other  times  the  action  is  violent  and  forcible, 
but  this  occurs  more  frequently  towards  the  end  of  the  attack. 
At  the  beginning  of  the  attack  the  arteries  are  like  cords,  and  the 
pulse  is  small  and  wiry,  but  in  the  course  of  the  attack  it  is 
feeble,  fluttering,  and  irregular,  and  in  the  remissions  it  becomes 


PORTION   OF   THE  SYMPATHETIC.  729 

full  and  soft.  Sphygmographic  tracings  show  an  increase  of 
arterial  tension  at  the  beginning,  and  lessened  tension  towards 
the  end  of  the  attack. 

During  a  paroxysm  of  angina  the  skin  is  generally  pale,  cold, 
and  dry,  that  of  the  hands  and  feet  being  almost  bloodless,  the 
face  is  pale  and  sunken,  the  patient  feels  chilled,  and  the  teeth 
chatter ;  but  towards  the  end  of  the  attack  the  opposite  condi- 
tions obtain,  the  surface  becomes  warm  and  red,  and  the  skin 
is  covered  with  abundant  perspiration.  The  duration  of  the 
paroxysm  is  generally  short,  usually  only  a  few  minutes,  but 
sometimes  the  attack  is  made  up  of  a  series  of  paroxysms,  each 
being  followed  by  a  remission  or  a  complete  intermission  of  the 
distressing  symptoms. 

The  course  of  the  disease  is  always  chronic.  The  attacks 
recur,  as  in  epilepsy^  at  extremely  variable  intervals.  At  times 
the  interval  may  extend  over  years,  while  in  other  cases  the 
attacks  recur  for  a  time  every  day  without  any  cause  being 
recognisable.  Great  bodily  and  mental  exertion  may  un- 
doubtedly provoke  an  attack,  and  it  may  sometimes  be  excited 
or  made  worse  by  pressure  on  some  points  which  are  sensitive 
either  constantly  or  only  during  the  attacks.  These  points  are 
the  spinous  and  transverse  processes  of  the  cervical  and  upper 
dorsal  vertebrae,  and  the  region  of  the  inferior  angle  of  the 
scapula.  As  time  advances,  the  attacks  usually  grow  worse  and 
recur  with  greater  frequency. 

§  323.  Morbid  Anatomy. — It  would  be  out  of  place  to  refer 
here  to  the  various  organic  diseases  with  which  angina  pectoris 
is  associated ;  the  only  cases  which  come  within  the  scope  of 
this  article  being  those  in  which  changes  have  been  discovered 
in  the  nervous  apparatus  of  the  heart.  In  a  case  of  angina 
under  the  care  of  Skoda  in  1841,  the  right  phrenic  nerve  was 
found  at  the  autopsy  made  by  Rokitanski  to  be  involved  in  a 
dark  blue,  hard  knot,  dotted  with  concretions  of  lime.  The 
cardiacus  magnus,  rising  from  the  cardiac  plexus  between  the 
pulmonary  artery  and  the  descending  aorta,  was  seen  to  enter 
into  a  black  nodule  of  the  size  of  a  hazel  nut.  Upon  the  ex- 
terior aspect  of  the  left  bronchus  the  descending  branches  of  the 
left  vagus  were  observed  similarly  interfered  with  by  a  blackish 


730  DISEASES  OF  THE  THORACIC 

lymphatic  gland  that  lay  beneath  them.  Dr.  Haddon^  found  the 
left  phrenic  nerve  compressed  by  a  bronchial  gland  of  the  size  of 
a  hazel  nut,  situated  close  to  the  root  of  the  left  lung.  In  this 
case  there  was  aneurisraal  dilatation  of  the  aorta,  so  that  it  is  very 
doubtful  whether  the  compression  of  the  phrenic  had  anything 
to  do  with  the  production  of  the  angina.  Lancereaux^  found 
microscopical  changes  in  the  cardiac  plexus  associated  with  an 
alteration  of  the  aorta  at  the  point  where  the  cardiac  plexus  lies 
upon  it ;  and  in  two  other  cases  he  found  similar  changes  along 
with  narrowing  of  the  coronary  arteries.  But  it  must  be  acknow- 
ledged that  in  all  these  cases  it  is  exceedingly  doubtful  how 
far  the  morbid  change  of  the  cardiac  plexus  had  produced  the 
symptoms,  inasmuch  as  they  might  have  been  caused  by  the 
organic  change  of  the  aorta  and  of  the  coronary  arteries.  The 
results  obtained  from  post-mortem  examination  with  respect  to 
diseases  of  the  nerves,  independently  of  disease  of  the  structure 
of  the  heart,  are,  indeed,  very  scanty,  and  it  would  be  precarious 
to  draw  definite  conclusions  from  them. 

§  324.  Morbid  Physiology. — Laennec  regarded  angina  pectoris 
as  a  neuralgia  of  the  nerves  of  the  heart,  and  Trousseau  as  an 
epileptiform  neuralgia;  while  Romberg  and  Friedreich  attri- 
buted it  to  hypersesthesia  of  the  cardiac  plexus.  Other  authors, 
however,  regard  the  alteration  in  the  action  of  the  heart  as  the 
prime  factor  in  the  disease,  and  relegate  the  pain  to  a  purely 
secondary  position.  Stokes,  for  instance,  thought  the  symptoms 
were  diie  to  a  temporary  increase  of  weakness  in  an  already 
weakened  heart,  and  Donnes  and  John  believed  that  the  essen- 
tial condition  was  a  paresis  or  paralysis  of  the  heart.  Eomberg 
thought  the  condition  due  to  increased  action  of  the  heart,  or  to 
a  hyperkinesis  with  hypersesthesia ;  and  von  Dusch  regarded  it 
as  a  hypersesthesia  combined  with  spasm  of  the  heart.  And 
opposite  as  these  opinions  may  appear  to  be,  all  of  them  may  be 
adumbrations  of  the  truth.  EichWald,^  however,  enunciated  a 
more  comprehensive  formula  for  the  condition  which  underlies 

1  Haddon.    Edinburgh  Medical  Journal.     Vol.  XVI.,  1870,  p.  45. 

^  Lancereaux.  "  De  I'alteration  de  I'aorte  et  du  plexus  cardiaque  dans  I'angine 
de  poitrine."    Gaz.  m^d.  de  Paris,  1864,  p.  432. 

^  Eichwald.  "  Ueber  das  VVesen  der  Stenokardie  und  ihr  Verhaltniss  zur 
subparalyse  des  Herzens."    Wiirzburger  med.  Zeitschrift,  1863. 


PORTION   OF  THE  SYMPATHETIC.  731 

angina,  when  he  attributed  the  symptoms  to  over-exertion  of  the 
heart,  caused  by  some  obstruction  to  the  onward  flow  of  blood. 
In  order  to  give  a  more  comprehensive  expression  to  the  hypo- 
thesis, it  may  be  assumed  that  the  essential  condition  which 
underlies  angina  is  a  disturbance  between  the  balance  which 
ought  to  be  maintained  between  the  propulsive  powers  of  the 
heart  and  the  resistance  to  be  overcome  in  such  a  way  that  the 
muscular  walls  of  the  heart  are  subjected  to  strain.  This  state 
may  result  from  all  conditions  which  weaken  the  muscular  power 
of  the  heart,  such  as  fatty  degeneration;  as  well  as  from  those 
conditions  which  cause  obstruction  to  the  onward  flow  of  blood, 
such  as  aortic  obstruction.  But,  as  already  pointed  out,  angina 
may  often  be  quite  independent  of  any  organic  disease  of  the 
heart,  and  in  these  cases  we  are  driven  to  look  to  the  nervous 
system  for  an  explanation  of  the  condition  which  causes  the 
disruption  between  the  propulsive  powers  of  the  heart  and  the 
resistance  to  the  onward  flow  of  blood.  The  idea  that  angina 
pectoris  must  be  ranked  amongst  the  vaso-motor  neuroses  occurred 
to  several  authors  independently  of  each  other.  Dr.  Lauder 
Brunton^  in  1866  found  from  sphygmographic  tracings  that  there 
was  increased  tension  in  the  arteries  during  the  attack,  which  he 
attributed  to  contraction  of  the  small  systemic  vessels.  This 
opinion  led  him  to  administer  the  nitrite  of  amyl  by  inhalation ; 
the  arterial  pressure  was  soon  lowered  and  the  attack  relieved. 
About  the  same  time  Landois^  subjected  the  symptoms  of  the 
affection  to  a  systematic  physiological  analysis,  and  showed  that 
it  might  be  divided  into  several  distinct  varieties. 

The  following  varieties  of  angina  pectoris  may  be  distinguished 
(§96):- 

1.  Automatio  Bxcito-motor  Ganglia  of  the  Heart. — Certain  poisons 
introduced  into  the  ventricular  cavity,  or  solutions  into  which  the  entire 
heart  is  plunged,  are  capable  of  immediately  arresting  the  action  of  the 
heart,  which  has  been  removed  from  the  chest  and  still  pulsates.  According 
to  the  experiments  of  Landois,^  weak  solutions  of  these  agents  injected  into 
the  endocardium  of  the  frog  stimulate  the  ganglia,  and  accelerate  the 

'  Brunton  (T.  Lauder).  "On  the  use  of  nitrite  of  amyl  in  angina  pectoris." 
The  Lancet,   Vol.  II.,  1867,  p.  97. 

*  Landois.  Correspondenzblatt  fiir  Psychiatrie,  1866 ;  and,  Der  Symptomen- 
complex  "  angina  pectoris  "  physiologisch  analysirt.     Koblenz,  1865. 

^  Landois.  Griefswalder  med.  Beitriige,  Bd.  II.,  1864,  p.  161 ;  Abstr.  Centralbl. 
f.  med.  Wissensch.,  Bd.  IL,  1864,  p.  486. 


732  DISEASES   OF  THE   THORACIC 

action  of  tlie  heart ;  while  stronger  solutions  of  the  same  agents  paralyse 
the  gangha  and  arrest  its  action.  Similar  states  of  the  ganglia  may  be 
induced  by  pathological  conditions  ;  and  when  these  morbid  conditions  are 
such  as  to  produce  irritation  of  the  ganglia,  the  rapidity  of  the  heart's 
movements  are  increased,  while  if  the  influence  exerted  on  the  gangha  be 
a  paralysing  one  the  rapidity  of  the  heart's  movements  is  diminished. 
Angina  is  associated  with  the  latter  condition. 

2.  Vagus  angina  pectoris  may  assume  two  forms,  (a)  The  first  is 
produced  by  causes  acting  directly  on  the  vagus.  Irritation  of  the  vagus  is 
indicated  by  a  full,  hard,  retarded  pulse,  increased  force  of  the  pulsations 
of  the  heart,  disturbance  of  phonation  and  deglutition,  and  sometimes 
temporary  arrest  of  the  action  of  the  heart.  Paralysis  of  the  vagus  is 
indicated  by  increased  rapidity  of  the  pulse,  which  may  beat  as  high  as 
from  216^  to  240^  times  in  a  minute.  This  form  of  accelerated  action  of 
the  heart  is  sometimes  associated  with  attacks  of  bronchial  asthma.^  (6) 
The  second  form  of  vagus  angina  pectoris  is  induced  by  reflex  causes, 
and  it  is  especially  frequent  in  diseases  of  the  abdominal  organs.  Landois 
has  called  this  form  angina  pectoris  reflectoria.  If  the  abdomen  of  a  frog 
be  laid  bare  and  the  intestine  be  struck  sharply,  as  with  the  handle  of  a 
scalpel,  the  heart  will  stand  still  in  diastole  with  all  the  phenomena  of 
vag-us  inhibition,  and  the  peripheral  irritation  which  results  from  disease 
may  produce  an  inhibitory  action  upon  the  heart. 

3.  Excito-motor  Sympathetic  Angina  Pectoris. — This  form  is  caused  by 
an  afi'ection  of  the  accelerator  nerves  of  the  heart,  which  run  with  the 
sympathetic,  and  the  symptoms  are  the  same  as  in  the  first  form  of  the 
affection.     The  most  probable  seat  of  the  lesion  is  the  cardiac  plexus. 

4.  Angina  Pectoris  Vaso-motoria. — Irritation  of  the  vaso-motor  nerves, 
which  run  for  the  most  part  in  the  sympathetic,  causes  contraction  of  the 
arterioles,  and  consequent  increased  resistance  to  the  ventricular  systole.* 
Marey  has  pointed  out  that  the  rapidity  of  the  beats  of  the  heart  is  in 
inverse  ratio  to  the  arterial  pressure  ;  hence  during  irritation  of  the  vaso- 
motor nerves  the  pulse  wiU  be  slow  and  hard,  and  there  wiU  be  paleness 
and  coldness  of  the  skin.  During  paralysis  of  the  vaso-motor  nerves,  the 
pulse  will  be  full  and  quick,  and  there  wiU  be  warmness  and  redness  of 
the  surface  ;  but  it  is  very  doubtful  whether  this  condition  ever  induces 
the  symptoms  of  angina,  although  it  very  generally  forms  a  secondary 
stage  of  the  affection  after  a  primary  stage  of  iiTitation. 

The  pain  which  forms  such  a  prominent  symptom  of  angina  pectoris 
is  due  to  neuralgia  of  the  cardiac  plexus  ;  but  like  other  forms  of  neuralgia 
it  may  be  induced  by  various  causes.     Eichwald  attributes  the  pain  to  the 

•  Weil.    Deutsches  Arch,  f .  klin.  Med.     Bd.  XIV.,  1874,  p.  89. 
^  von  Huppert.     Berl.  klin.  Wochenschr.     1874.     No.  31. 

^  Kredel,  "  Zur  Lehre  von  den  Vagusneurosen."  Deutsches  Arch,  f .  klin.  Med., 
Bd.  XXX.,  1882,  p.  546. 

*  Nothnagel.  "  Angina  pectoris  vaso-motoria,"  Deutsches  Arch,  fiir  klin. 
Med.,  Bd.  III.,  1867,  p.  309;  and  "Ueber  arythmia  hertztatigkeit,"  Deutsches 
Arch,  fiir  klin.  Med.,  Bd.  XVII.,  p.  190. 


PORTION   OF  THE  SYMPATHETIC.  733 

over-exertion  of  the  heart  to  overcome  an  obstruction,  just  as  over-action 
of  other  muscles,  both  voluntary  and  involuntary,  is  painful,  such  as  cramp 
of  the  calf  and  contraction  of  the  uterus.  It  is  certain,  however,  that  the 
pain  may  be  produced  by  many  causes,  such  as  mechanical  pressure  and 
other  injuries  of  the  cardiac  plexus,  and  antemia  of  the  cardiac  nerves  and 
ganglia  due  to  ossification  of  the  coronary  arteries  and  disease  of  the 
aortic  valves. 

The  pains  which  radiate  from  the  preecordial  region  to  other  parts  of 
the  body,  especially  the  thorax  and  arm,  are  rendered  intelligible  by  the 
anatomical  connections  subsisting  between  the  cardiac  plexus  and  cervical 
nerves,  through  the  medium  of  the  cervical  ganglia. 

§  325.  Diagnosis  and  Prognosis. — The  diagnosis  resolves 
itself  into  the  question  whether  there  is  organic  disease  of  the 
heart,  or  whether  the  symptoms  are  due  purely  to  a  disturbance 
of  the  nervous  system.  This  question  must  be  determined  by  a 
careful  physical  examination,  giving  due  weight  to  concomitant 
circumstances,  such  as  the  age  and  general  condition  of  the 
patient. 

The  prognosis  depends  to  a  considerable  extent  upon  the 
gravity  of  the  accompanying  organic  changes,  but  it  is  always 
grave  in  true  angina  pectoris. 

§  326.  Treatment. — In  cases  where  physical  examination  shows 
that  the  angina  is  symptomatic  of  structural  disease  of  the  valves 
of  the  heart  or  great  vessels  or  on  arterio-capillary  fibrosis,  the 
treatment  resolves  itself  into  that  which  is  appropriate  for  the 
graver  affection.  When  the  symptoms  depend  upon  abdominal 
disease  or  excessive  tobacco-smoking,  an  endeavour  must  be 
made  to  remove  the  cause  of  the  disease. 

If  the  affection  be  of  nervous  origin  the  treatment  must  be 
directed  to  remove  the  symptoms.  The  remedies  most  usually 
employed  are  diffusible  stimulants  and  so-called  antispasmodics, 
such  as  alcohol  in  its  various  forms,  the  various  ethers,  valerian, 
musk,  castor,  camphor,  and  succinate  of  ammonia.  Ether  or  chloro- 
form inhalation  may  be  cautiously  employed,  but  without  pro- 
ducing full  narcosis.  Narcotics  are  also  useful,  especially  the 
subcutaneous  injection  of  morphia.  Atropine  and  conia  have 
been  recommended,  but  both  appear  to  be  inferior  to  morphia. 

In  the  cases  in  which  vascular  spasm  is  present,  the  inhalation 
of  nitrite  of  amyl  sometimes  gives  immediate  relief.      Such  a 


734  DISEASES   OF  THE  THORACIC 

powerful  remedy  requires,  of  course,  to  be  used  cautiously.  In 
cases  characterised  by  violent  and  accelerated  action  of  the 
heart  due  to  abnormal  irritation  of  the  automatic  ganglia,  or  the 
excito-motor  fibres  of  the  sympathetic,  such  agents  as  atropine, 
conia,  aconite,  and  veratria  may  be  found  useful. 

In  order  to  prevent  a  recurrence  of  the  attacks,  the  action  of 
the  heart  must  be  strengthened.  Various  remedies  have  been 
employed  for  this  purpose,  but  probably  iron,  arsenic,  and  digi- 
talis are  the  remedies  which  are  most  to  be  depended  upon. 
Sulphate  of  zinc,  cyanide  of  zinc,  nitrate  of  silver,  bromide  of 
potassium,  and  bromide  of  calcium  are  other  remedies  which 
have  been  recommended  by  various  authors,  and  which  may 
occasionally  be  useful,  although  less  applicable  than  the  three 
remedies  just  mentioned.  Quinine,  phosphoric  acid,  inhalation 
of  oxygen,  and  hydrocyanic  acid  have  also  proved  serviceable  in 
certain  cases.  Counter-irritation  of  the  cardiac  region  was  at  one 
time  a  favourite  remedy,  and  it  is  quite  possible  that  it  is  rather 
too  much  neglected  in  the  present  day.  A  great  deal  of  benefit 
is  found  in  some  cases  from  covering  the  prsecordial  region  with 
a  belladonna  plaster. 

The  induced  current  in  the  form  of  the  faradic  brush  has  been 
employed  by  Duchenne,^  who  thought  that  he  produced  a  perma- 
nent cure  in  two  cases — one  being  a  case  of  the  uncomplicated 
nervous  form,  and  the  other  hysterical.  Cutaneous  irritation  by 
means  of  faradisation  acts  in  a  reflex  manner  on  the  nerves  of  the 
heart  and  the  vaso-motor  nervous  system.  Weak  interrupted 
currents  strengthen  the  contractions  of  the  heart,  accelerate  the 
circulation,  and  contract  the  vessels  by  reflex  excitation  of  the 
excito-motor  and  vaso-motor  nervous  apparatus ;  but  strong 
faradic  currents  weaken  the  contractions  of  the  heart,  retard  the 
circulation,  and  dilate  the  vessels  by  reflex  excitation  of  the  regu- 
lator nerves  of  the  heart  and  paralysis  of  the  vaso-motor  centres. 
Severe  cutaneous  irritation,  therefore,  is  only  justified  when  the 
action  of  the  heart  is  powerful,  rapid,  and  violent,  with  contracted 
arteries  and  small  tense  pulse.  The  same  considerations  must 
direct  our  employment  of  galvanisation ;  the  strong  currents 
must  be  applied  so  as  to  influence  the  regulator  nerves  of  the 

1  Duchenne.  "  Note  sur  I'influence  th^rapeutique  de  Texoitation  ^lectro-cutanee 
dans  I'angiae  de  poitrine."    Bull,  de  th&ap.,  1853. 


PORTION   OF  THE   SYMPATHETIC.  735 

heart  only  when  the  action  of  the  heart  is  quick  and  violent ; 
while  weak  currents  must  be  used  to  the  cervical  sympathetic 
and  cervical  vagus  when  the  action  is  slow  and  feeble.  When  it 
it  is  desired  to  act  on  the  inhibitory  nerves  strong  stabile  cur- 
rents may  be  used ;  the  positive  pole  should  be  placed  on  the 
sternum,  while  the  negative  is  placed  on  the  lower  cervical  ver- 
tebrae. In  a  case  of  supposed  rheumatic  origin,  von  Huebner^ 
obtained  a  complete  cure  by  placing  the  positive  pole  upon  the 
supersternal  fossa,  and  the  negative  upon  the  cervical  ganglia  of 
the  sympathetic  on  each  side  in  succession.  He  placed  the  posi- 
tive pole  over  the  lowest  cervical  ganglion  and  the  negative  upon 
the  sensitive  spots  at  the  angles  of  both  shoulder  blades.  At 
first  weak  currents  were  used,  and  the  attacks  ceased  after  the 
first  sitting,  and  did  not  return. 

'  von  Huebner.      "  Zur  Therapie  der  Angina  pectoris."     Deutsches  Arch.  f. 
klin.  Med.,  Bd.  XII.,  1S73,  p.  514. 


736 


CHAPTER  IV. 


DISEASES    OF    THE    ABDOMINAL    POETION    OF    THE 
SYMPATHETIC. 

(I.) -NEUROSES    OF   THE    CCELIAC    PLEXUS. 

NevbTolgia  Mesenterica  {Colic,  Enteralgia,  Colica  Satwrnina.) 

§  327.  Enteralgia,  or  intestinal  colic,  consists  of  paroxysms  of 
pain  in  the  abdomen,  having  their  seat  of  maximum  intensity 
about  the  umbilical  region. 

Etiology. — Any  source  of  irritation  of  the  mucous  membrane 
of  the  alimentary  canal  may  give  rise  to  colic,  such  as  undi- 
gested or  irritating  food,  cold  drinks  or  ices,  retained  faeces, 
and  the  presence  of  gall  stones  or  worms.  The  source  of  the 
irritation  may  be  in  the  mucous  membrane  itself;  hence  colic  is 
often  a  prominent  symptom  of  organic  disease  and  obstruction 
of  the  intestines.  The  origin  of  the  irritation  may  be  remote 
and  indirect ;  hence  intestinal  colic  may  likewise  be  a  symptom 
of  ovarian  and  uterine  affections,  or  result  from  the  passage  of 
hepatic  or  renal  calculi.  Exposure  to  cold  is  a  frequent  cause 
of  colic,  and  it  is  thus  probably  produced  in  a  reflex  manner. 
Diseases  in  other  parts  of  the  nervous  system  may  cause  colic, 
and  it  is  especially  frequent  as  a  symptom  of  hysteria.  Intes- 
tinal colic  is  sometimes  caused  by  certain  morbid  poisons  in 
the  blood,  as  gout  and  rheumatism ;  but  chronic  lead  poisoning 
produces  the  severest  and  most  obstinate  form  of  colic,  although 
the  affection  may  be  a  symptom  of  chronic  copper  poisoning, 
and  may  probably  be  caused  by  other  mineral  poisons. 

Symptoms. — Severe  pains  are  felt  in  the  abdomen,  which 


ABDOMINAL  PORTION  OF  THE  SYMPATHETIC.      737 

usually  occur  quite  suddenly,  without  any  premonitory  symp- 
tom. The  pains  are  described  as  being  of  a  twisting,  pinching, 
or  griping  character.  They  begin  and  are  most  severe  about 
the  umbilical  region,  but  may  spread  over  the  entire  abdomen, 
and  are  liable  to  change  their  position.  The  pains  occur  in 
paroxysms,  which  are  followed  by  periods  of  remission  or  com- 
plete intermission.  Pressure  of  the  abdomen  almost  always 
affords  relief,  and  the  patient  usually  bends  forwards  or  lies  with 
the  face  downwards,  and  presses  it  with  both  hands.  A  diffused 
tenderness  of  the  abdominal  walls,  on  deep  pressure,  especially 
if  suddenly  applied,  is  not  unfrequently  experienced. 

The  bowels  are  usually  constipated,  and  distended  with  flatus, 
so  that  a  very  tympanitic  note  is  afforded  on  percussion,  and  the 
rolling  about  of  flatus  can  often  be  felt  when  the  hand  is  placed 
on  the  abdomen,  while  the  abdominal  muscles  are  felt  contracted, 
hard,  and  knotty.  Colic  may  occasionally  be  associated  with 
diarrhoea.  In  lead  colic  the  abdomen  is  retracted,  there  is 
obstinate  constipation,  nausea,  vomiting,  eructations,  and  hiccup; 
while  the  blue  line  on  the  gums  will  indicate  the  presence  of 
the  poison  in  the  system. 

Disorders  of  the  circulation  are  usually  associated  with  every 
form  of  colic.  During  the  attack  the  face  and  extremities  are 
pale  and  cold,  and  the  action  of  the  heart  becomes  slow  and 
feeble,  and  if  the  attack  be  prolonged  there  may  be  symptoms  of 
more  or  less  complete  collapse.  The  action  of  the  heart  is  un- 
usually weak  in  lead  colic,  and  the  pulse,  although  occasionally 
quickened,  is  as  a  rule  rendered  slow.  Out  of  1,217  cases 
collected  by  Tanquerel,  the  frequency  of  the  pulse  in  678  was 
only  from  thirty  to  sixty  in  the  minute;  and  Eulenburg  observed 
cases  in  which  the  pulse  beat  only  twenty-eight  times  in  the 
minute.  Cases  have  been  observed,  however,  in  which  there 
has  been  increased  frequency  of  the  pulse.  Romberg  has  drawn 
attention  to  the  fact  that  patients  suffering  from  intestinal  and 
other  forms  of  colic  experience  a  subjective  sensation  of  faint- 
ness  and  weakness,  and  a  sense  of  impending  death  more  or  less 
similar  to  those  felt  during  attacks  of  angina. 

§  328.  Pathology. — It  is  wholly  unnecessary  to  enter  here 
into  a  detailed  account  of  the  various  opinions  held  with  regard 
VOL.  L  vv 


738  DISEASES  OF  THE   ABDOMINAL 

to  the  nature  of  colic,  and  we  need  not  enter  on  the  question 
whether  it  is  to  be  regarded  as  a  hypersesthesia,  or  a  neuralgia  of 
the  mesenteric  plexus  and  its  ganglia.  Ludwig  has  found  that 
the  splanchnic  nerves  are  highly  sensitive  to  nervous  impressions, 
and,  consequently,  it  is  very  probable  that  the  painful  impres- 
sions reach  the  sensorium  through  these  nerves,  Eulenburg  and 
Guttmann  suggest  that  the  sensory  fibres  which  surround  the 
abdominal  arteries  may  also  be  involved  in  the  enteralgic  attack. 
The  disorders  of  the  circulation  are  to  be  explained  by  supposing 
that  the  irritation  of  the  intestines  is  conveyed  by  afferent  fibres 
to  the  centre  of  the  vagus  in  the  medulla  oblongata,  and  thence 
reflected  outwards  to  the  heart,  inhibiting  its  action,  as  occurs  in 
Goltz's  percussion  experiments  with  the  intestines  of  the  frog. 
It  must,  however,  be  remembered  that  Marshall  Hall  arrested 
the  action  of  the  heart  of  an  eel  by  crushing  the  stomach  after 
the  brain  and  spinal  cord  had  been  entirely  removed ;  so  that 
the  irritation  must  have  been  conveyed  from  the  latter  to  the 
former  without  the  intervention  of  the  medulla  oblongata. 

§  329.  Treatment — The  first  aim  of  treatment  must  be  to 
remove  the  cause  of  the  affection.  As  constipation  is  usually 
present,  a  free  aperient  must  be  administered,  and  probably  the 
best  for  the  purpose  is  a  full  dose  of  castor  oil.  If  the  pain  be 
severe,  twenty  to  thirty  drops  of  tincture  of  opium  may  be  given 
along  with  the  oil.  Other  forms  of  aperient  may  do  equally 
well,  or  the  bowels  may  be  evacuated  by  means  of  enemata  of 
warm  water.  Carminative  drinks,  or  some  spirit  and  hot  water, 
are  useful  during  the  attack,  and  if  hysteria  is  associated  with 
the  attack  a  draught  containing  tincture  of  valerian  or  asafoetida 
is  indicated.  For  the  relief  of  pain  the  greatest  reliance  must  be 
placed,  as  usual,  upon  opium — either  a  full  dose  of  the  tincture 
or  a  subcutaneous  injection  of  morphia.  Fomentations  over  the 
abdomen  or  dry  heat  with  friction  are  useful  adjuncts  in  treat- 
ment, and  if  any  signs  of  collapse  supervene  diffusible  stimulants 
must  be  given  more  or  less  freely,  according  to  circumstances. 
In  lead  colic  the  poison  must  be  eliminated  by  means  of  vapour 
baths,  diaphoretics  like  jaborandi,  and  above  all  by  the  adminis- 
tration of  iodide  of  potassium,  which  renders  soluble  the  lead 
which  has   been    deposited   in    the   tissues.      The   faradic   and 


POETION  OF   THE   SYMPATHETIC.  739 

galvanic  currents  may  be  useful  in  the  treatment  of  tlie  affection, 
although  their  efficacy  has  not  as  yet  been  indubitably  proved. 

Spasm  and  Paralysis  in  the  Region  of  the  Cceliac  Plexus. 

§  330.  The  movements  of  the  larger  portion  of  the  intestinal 
tract  from  the  stomach  to  the  transverse  colon  are  regulated 
through  the  splanchnic  nerves ;  and  consequently  the  motor 
disturbances  to  which  these  organs  are  liable  are  in  great  part 
caused  by  disorders  of  the  sympathetic  system.  The  vomiting 
which  accompanies  hysteria,  neurasthenia,  and  other  nervous 
diseases  is  in  all  probability  often  due  to  implication  either 
directly  or  indirectly  of  the  sympathetic  system.  Reflex  vomit- 
ing accompanies  the  passage  of  a  gall  stone  or  renal  calculus, 
as  well  as  other  diseases  attended  by  severe  pain. 

Irritation  or  paralysis  of  the  regulatory  fibres  of  the  splanchnic 
nerves  may  give  rise  to  obstinate  constipation,  or  to  an  increased 
peristaltic  action  of  the  bowels.  The  obstinate  constipation  of 
lead  colic  may  be  taken  as  an  example  of  the  former,  and  the 
increased  peristaltic  action  caused  by  various  purgative  medicines 
of  the  latter. 

(IIO-NETTEOSES    OF   THE   GASTRIC   PLEXUS. 

Some  of  the  sensory  neuroses,  as  Pyrosis,  Bulimia,  and  Poly- 
phagia, which  occur  in  the  territory  of  distribution  of  the  gastric 
plexus,  and  the  motor  disorders  caused  by  irritation  of  the 
pneumogastric  nerves,  have  been  already  described  (§  63),  and 
it  only  remains  to  mention  briefly  the  neuralgic  attacks  which 
occur  in  this  region. 

Neuralgia  Gastrica  { Cardialgia,  Gastralgia,  Gastrodynia, 
Neuralgiea,  Neuralgia  Cceliaca). 

§  331.  Gastrodynia  is  characterised  by  paroxysmal  attacks  of 
pain  in  the  epigastric  region,  which  may  radiate  upwards  to 
the  back  between  the  shoulders,  or  towards  the  middle  of  the 
sternum.  The  attack  usually  comes  on  suddenly,  without  any 
premonitory  symptom,  and  the  pain,  which  is  very  severe,  gene- 
rally intermits  after  a  few  minutes,  but  soon  recurs  with  greater 
intensity,  and  after  repeated  intermissions  and  recurrences  it 


740  DISEASES  OF  THE  ABDOMINAL 

finally  disappears.  Tenderness  of  the  epigastrium  on  pressure  is 
not  usually  present,  the  pain  being,  on  the  contrary,  often  relieved 
by  firm  and  continuous  pressure.  Pressure  on  the  cartilages  of 
the  false  ribs  on  the  left  side  or  on  the  corresponding  intercostal 
spaces  may  cause  pain,  and  the  spinous  processes  of  some  of  the 
vertebrae  may  be  tender  on  pressure.  During  the  attack  the 
upper  portions  of  the  recti  muscles  are  strongly  contracted,  and 
the  abdominal  walls  are  consequently  rendered  tense  and  un- 
yielding, whilst  the  epigastric  region  is  usually  retracted.  The 
pulse  is  generally  slow  and  feeble ;  the  arterial  tension  is  low ; 
the  extremities  are  cold  and  pale ;  and  towards  the  end  of  a 
severe  attack  the  patient  may  suffer  from  general  chilliness,  and 
a  feeling  of  oppression  and  faintness  like  that  of  angina  pectoris 
reflectoria.  The  paroxysm  often  terminates  by  copious  vomiting; 
the  food  contained  in  the  stomach  is  first  ejected,  and  then  large 
quantities  of  watery  fluid  mixed  with  bile  and  mucus,  and  if  the 
urine  be  examined  during  or  soon  after  the  attack  it  is  often 
found  to  contain  a  small  quantity  of  albumen.^ 

The  duration  of  the  attack  varies  from  a  few  minutes  to  a  few 
hours,  or  even  to  a  few  days,  and  during  the  interval  the  patient 
is  free  from  pain.  The  recurrence  of  the  attacks  is  very  irregular; 
at  times  they  occur  daily,  while  at  other  times  years  may  inter- 
vene between  two  attacks. 

The  etiology  of  the  disease  is  obscure.  The  affection  is  more 
common  in  youth  than  in  old  age  and  in  women  than  in  men.  It 
is  often  associated  with  anaemia  and  chlorosis,  and  is  not  an  un- 
frequent  manifestation  of  hysteria.  Hereditary  predisposition  to 
the  affection  can  occasionally  be  traced,  and  a  depressed  nutritive 
condition  predisposes  to  gastralgia  as  to  other  forms  of  neuralgia. 
The  stomach  is  free  from  structural  change,  and  the  digestion 
may  in  other  respects  be  carried  on  satisfactorily.  Gastralgic 
attacks  are  not  unfrequent  in  certain  diseases  of  the  spinal  cord, 
especially  in  tabes  dorsalis. 

Diagnosis. — The  pain  of  gastric  neuralgia  occurs  in  paroxysms 
with  perfectly  free  intervals,  it  occurs  independently  of  the  kind 
of  food  taken  into  the  stomach,  and  it  is  relieved  by  pressure 
on  the  epigastrium,  and  the  nutrition  of  the  patient  is  rarely 

'  Fischl  (J.).  "Ueber  einige  Ursachen  von  transitorischer  Albuminurie." 
Deutschfrs  Arch.  f.  klin.  Med.,  Ed.  XXIX.,  1881,  p.  225. 


PORTION   OF  THE  SYMPATHETIC.  741 

afifected.  In  chronic  structural  diseases  of  the  stomach,  on  the 
other  hand,  the  pain  is  increased  by  the  action  of  anything 
which  irritates  the  mucous  membrane  of  the  stomach  ;  it  occurs 
soon  after  partaking  of  food,  more  especially  if  the  food  or  drink 
contain  anything  pungent  or  irritating,  it  is  increased  by  deep 
pressure  over  the  epigastrium,  and  the  patient  becomes  pro- 
gressively emaciated,  and  assumes  a  cachectic  appearance. 

Prognosis. — The  prognosis  of  gastric  neuralgia  is  generally 
favourable,  except  when  it  depends  upon  hysteria,  or  a  central 
lesion  like  locomotor  ataxy. 

Treatment. — The  causes  must  first  be  removed.  When  it 
occurs  in  young,  angemic,  and  chlorotic  females,  the  usual  treat- 
ment of  these  affections  must  be  adopted.  If  a  malarial  origin 
be  suspected,  quinine  is  likely  to  prove  an  effectual  remedy.  In 
many  cases  a  cure  is  effected  by  tbe  removal  of  other  local 
diseases,  as  metritis,  or  ulceration  of  the  os  uteri.  In  the  great 
majority  of  cases,  the  treatment  must  be  palliative,  and  directed 
to  allay  the  local  pain.  The  most  usual  remedies  for  this  pur- 
pose are  bismuth,  nitrate  and  oxide  of  silver,  opium,  or  the 
subcutaneous  injection  of  morphia.  I  have  several  times  found 
the  constant  current  useful,  the  positive  pole  being  placed  on 
the  sternum,  and  a  large  negative  pole  on  the  epigastrium. 

(IIL)— NEUROSES    OF   THE   HEPATIC   PLEXUS. 

NEURALGIA   HEPATICA   (hEPATALGIa). 

§  332.  Hepatic  colic  is  usually  the  result  of  the  passage  of 
biliary  calculi  through  the  cystic  and  common  ducts.  Paroxysms 
of  similar  pain,  however,  occur  at  times  in  neurotic  subjects,  in 
the  entire  absence  of  jaundice  and  the  other  symptoms  which 
indicate  the  passage  of  gall  stones,  and  when  no  other  source  of 
irritation  can  be  discovered ;  hence  these  are  regarded  as  of 
purely  neuralgic  origin. 

Symptoms. — The  symptoms  of  hepatic  colic  are  more  or  less 
severe  pain  coming  on  suddenly  and  lasting  with  irregular  inter- 
missions and  exacerbations  a  few  hours  or  a  few  days.  The 
pain  is  often  very  severe,  and  of  an  aching,  cutting,  or  tearing 
character,  and  is  usually  attended  with  a  sense  of  constriction  or 
cramp.     It  is  generally  referred  to  the  pit  of  the  stomach,  or  to 


742  DISEASES   OF  THE  ABDOMINAL 

the  umbilicus,  wlience  it  radiates  to  the  back  between  the 
shoulders,  but  never  downwards.  The  patient  suffers  during  a 
severe  attack  from  faintness,  nausea,  and  vomiting,  the  action  of 
the  heart  is  weakened  and  the  surface  of  the  body  is  cold,  and 
in  severe  cases  there  are  symptoms  of  collapse. 

Treatment. — The  treatment  of  hepatic  colic  must  be  conducted 
on  the  same  principles  as  for  enteralgia,  by  fomentations  and 
narcotics,  and  the  removal  of  the  ezciting  cause. 

Addison's  Disease  (Bronzed  Skin). 

§  333.  The  peculiar  cachexia  and  pigmentation  of  the  skin,  which  con- 
stitute the  chief  clinical  features  of  Addison's  disease,  have  almost  always 
been  found  associated  with  disease  of  the  supra-renal  capsules.  The  semi- 
lunar gangha  and  solar  plexus  are,  however,  frequently  imphcated  in  the 
disease,  and  some  pathologists  regard  the  affection  of  the  sympathetic  as  the 
primary  and  fundamental  anatomical  change,  and  that  upon  which  the 
symptoms  depend.  A  large  number  of  post-mortem  examinations  might 
be  cited  in  favour  of  this  opinion  ;  but  so  long  as  the  nervous  origin  of  the 
disease  is  uncertain,  it  will  be  better  to  refer  the  reader  to  other  sources  of 
information  with  regard  to  this  affection. 

Diabetes  Mellitus. 

§  334,  The  vaso-motor  nerves  of  the  liver  take  their  origin  on  the  floor  of 
the  fourth  ventricle,  and  pass  through  the  cervical  and  upper  dorsal  regions 
of  the  spinal  cord,  and  the  rami  communicantes  opposite  the  foiirth  or  fifth 
dorsal  vertebra,  to  join  the  sympathetic,  and  iJtimately  enter  the  organ  as 
the  hepatic  plexus.  Injury  to  these  fibres,  either  at  their  origin  in  the  floor 
of  the  fourth  ventricle,  or  in  any  part  of  their  course  in  the  spinal  cord,  or 
in  the  sympathetic  itself,  produces  a  paralytic  dilatation  of  the  vessels  of 
the  liver,  that  is  followed  by  an  increased  formation  of  sugar  in  the  organ, 
which  is  eventually  eliminated  by  the  kidneys.  There  can  be  no  doubt 
that  many  forms  of  diabetes  mellitus  are  similarly  caused.  Many  cases  of 
diabetes  are  caused  by  injury  or  disease  of  the  brain,  involving  the  floor  of 
the  fourth  ventricle,  or  the  parts  near  it.  Diabetes  has  also  been  fovmd  to 
foUow  division  of  the  sciatic  nerve  in  animals,  and  sugar  has  recently  been 
detected  in  the  urine  in  certain  cases  of  sciatica  (Braun). 

(IV.)-NEUROSES  OF  THE  HYPOGASTEIC   PLEXUS   (NEURALGIA 
HYPOGASTEICA). 

§  335.  Hypogastric  neuralgia  was  first  described  by  Romberg, 
and  consists,  according  to  that  observer,  of  painful  sensations  in 
the  lower  abdominal  and  sacral  regions  radiating  to  the  upper 
part  of  the  thigh  and  the  parts  supplied  by  the  spinal  hsemor- 


POETION   OF  THE   SYMPATHETIC.  743 

rLoidai  nerves.  It  is  usually  met  with  in  females  in  connection 
with  hysteria  and  irregularities  of  menstruation,  and  frequently 
occurs  at  the  commencement  of  puberty.  Various  forms  of  hypo- 
gastric neuralgia  may  be  observed  according  to  the  branches 
affected.  In  one  case  the  utero-vaginal  plexus  may  be  affected, 
giving  rise  to  hysteralgia,  in  another  the  haemorrhoidal  plexus 
may  be  the  seat  of  the  disease  constituting  neuralgia  of  the 
anus.  At  another  time  the  ovary  is  the  seat  of  the  disease,  and 
then  it  is  called  ovarialgia.  When  the  spermatic  plexus  is 
affected,  it  constitutes  what  has  been  described  as  irritable  testis 
and  neuralgia  testis.  At  other  times  the  urethra  in  men  is 
affected,  constituting  neuralgia  urethralis. 

Neuralgia  of  the  Rectum. 

§  336.  Neuralgia  of  the  rectum  in  its  pure  form  is  rare,  and  there  can 
be  little  doubt  that  a  great  many  of  the  cases  which  have  been  described 
as  such  were  instances  of  slight  fissure  of  the  anus.  Dr.  Anstie  observed 
a  case  where  the  most  careful  examination  failed  to  detect  a  fissure. 

The  symptoms  consisted  of  severe  paroxysms,  of  cutting  pains  coming 
on  suddenly  and  spontaneously  after  exposui'e  to  cold,  situated  one  inch 
within  the  anus,  and  greatly  increased  by  defecation.  Neuralgic  pain  in 
the  rectum  is  a  common  symptom  of  locomotor  ataxia. 

Treatment. — Besides  the  usual  treatment  of  neuralgia,  suppositories  of 
morphia  or  subcutaneous  injection  of  atropine  (Anstie)  should  be  used. 
The  galvanic  current  may  be  employed  locally  by  a  suitable  electrode. 

Uterine  Neuralgia. 

§  337.  The  following  are  the  causes  which  Dr.  Anstie  thought  would  give 
rise  to  uterine  neuralgia :  Ascarides  in  the  rectum,  profuse  and  intractable 
leucorrhoea,  calculus  in  the  kidney  or  ureter,  prolapse  of  the  uterus,  uterine 
tumours  of  aU  kinds,  ulceration  of  the  cervix,  and  scybalee  impacted  in  the 
rectum,  or  the  source  of  the  irritation  may  be  in  some  distant  part  of  the 
body.  In  this  disease,  which  was  first  described  by  Gooch  as  irritable 
uterus,  severe  uterine  pain,  which  is  hable  to  periodical  exacerbations,  may 
exist  in  the  absence  of  any  recognisable  disease  of  the  pelvic  organs,  and 
the  patient  has  generally  suffered  on  previous  occasions  fi'om  neuralgia 
in  some  other  part  of  the  body. 

The  patient  complains  of  paroxysmal  attacks  of  intense  pain  deep  in  the 
pelvis,  whch  is  aggravated  by  movements,  by  the  maintenance  of  the  erect 
postm-e,  and  by  pressure  on  the  cervix.  The  pain  often  radiates  to  the 
inguinal  and  lumbar  regions,  generally  on  one  side,  and  is  often  worse  at 
the  menstrual  periods,  although  this  is  not  an  invariable  rule. 


44  DISEASES  OF  THE  ABDOMINAL 

Vaginismus  is  a  condition  of  intense  sensibility  of  the  vaginal  orifice, 
which  renders  coitus  impossible.  It  is  often  associated  with  spasm  of  the 
constrictor  vaginse  and  of  the  levator  ani,  and  attempts  at  coition  may 
induce  general  hysterical  convulsions. 

Ovarialgia — Ovarian  HTPERissTHESiA. 

§  338.  Ovarian  neuralgia  may  be  caused  by  any  of  the  sources  of  irrita- 
tion already  enumerated  as  the  causes  of  uterine  neuralgia.  It  is  frequently 
associated  with  grave  hysterical  phenomena,  but  it  is  difficult  to  determine 
whether  the  ovarian  pain  is  to  be  regarded  as  the  cause  of  the  hysterical 
symptoms,  or  as  the  effect  of  the  central  affection  which  vmderUes  hysteria. 
The  left  ovary  is  most  usually  affected. 

Symptoms. — Particular  attention  has  recently  been  drawn  to  ovarialgia 
by  Charcot  and  his  pupils.  The  symptoms  consist  of  pain,  which  is  some- 
times so  acute  that  the  patient  cannot  tolerate  the  slightest  touch,  and  which 
is  localised  partly  in  the  hypogastrium  and  partly  in  the  iliac  fossa.  In  many 
cases  the  pain  is  only  discovered  by  deep  pressure  over  either  ovary,  and  in 
these  cases  there  is  more  or  less  complete  anaesthesia  of  the  abdominal  walls, 
and  the  seat  of  the  pain  is  much  more  circumscribed  than  in  the  former 
variety.  Deep  pressure  over  the  iliac  region  enables  the  investigator  to  feel 
the  concave  curve  formed  by  the  superior  inlet  of  the  pelvis,  and  towards 
its  middle  the  hand  will  feel  an  ovoid  body  elongated  transversely,  and 
which  is  frequently  swollen  to  the  size  of  an  oUve  or  a  small  egg  (Charcot). 
Pressure  exaggerates  this  fixed  iliac  pain,  and  causes  it  to  irradiate  towards 
the  epigastrium  and  throat.  The  irradiation  of  the  pain  towards  the  epi- 
gastrium is  often  accompanied  by  nausea  and  vomiting,  and  if  the  pressure 
be  continued  palpitations  of  the  heart,  increased  frequency  of  the  pulse,  and 
a  sensation  of  "globus  hystericus"  supervene.  Besides  these  symptoms 
which  constitute  the  usual  premonitory  symptoms  of  a  hysterical  attack,  or 
the  hysterical  aura,  Charcot  describes  other  symptoms  in  continuation  of 
this.  These  symptoms  are,  in  case  of  compression  of  the  left  ovary, 
"  intense  sibilant  sounds  in  the  left  ear,  which  the  patients  compare  to  the 
hissing  noise  produced  by  the  whistle  of  a  railway  engine ;  a  sensation  as  of 
blows  from  a  hammer  falling  on  the  left  temporal  region ;  and,  lastly,  a 
marked  obscurity  of  sight  in  the  left  eye."  Similar  phenomena  occm'  on 
the  corresponding  parts  on  the  right  side  when  pressure  is  applied  over  a 
right  hypereesthetic  ovary. 

Treatment. — The  treatment  of  such  cases  presents  many  difficulties.  In 
some  cases  seclusion  of  the  patient,  prolonged  rest  in  bed,  over-feeding, 
massage,  and  electricity  is  attended  by  success,  this  being  the  treatment 
recommended  by  Weir  Mitchell  for  aggravated  cases  of  neurasthenia. 
When  this  treatment  fails  the  physician  should  take  it  into  his  serious 
consideration  whether  or  not  he  ought  to  recommend  the  operation  of 
oophorectomy. 


PORTION   OF  THE   SYMPATHETIC.  745 


Neuralgia  of  the  Testis. 

§  339.  Neuralgia  of  the  testis  is  by  no  means  so  common  an  aflfection  as 
neuralgia  of  the  ovary.  Severe  neuralgic  pains  in  the  testis  occur  as  the 
result  of  morbid  growth  in  the  organ,  and  as  a  symptom  of  a  renal  calculus 
descending  the  ureter.  Dr.  Anstie  observed  it  as  a  reflex  effect  of  herpes, 
and  it  is  not  uncommon  in  neurotic  subjects,  as  the  result  of  self  abuse. 

Neuralgia  of  the  testicle  consists  of  paroxysms  of  severe  pain  arising 
spontaneously  and  usually  unilaterally,  and  seated  partly  in  the  testicle  and 
IDartly  in  the  epididymus  and  cord.  The  organ  is  tender  to  pressure  and 
contact,  and  between  the  paroxysms  of  pain  a  certain  amount  of  dull  aching 
pain  is  complained  of.  During  the  attacks  of  pain  the  testicle  is  strongly 
retracted  owing  to  spasm  of  the  cremaster  muscle,  and  they  ax'e  frequently 
attended  with  fainting  and  vomiting. 

This  affection  is  usually  very  obstinate,  and  it  is  often  accompanied  by 
great  mental  depression,  which  may  end  in  confirmed  hypochondriasis  or 
melancholia. 

Treatment. — Tonic  treatment,  consisting  of  iron  and  quinine,  along  with 
cold  douches,  sitz  baths,  and  sea  baths,  has  been  found  useful ;  nervine 
tonics,  as  arsenic,  zinc,  bromide  of  potassium,  have  also  been  recommended. 
A  suspensory  bandage  should  be  worn,  and  the  subcutaneous  injection  of 
morphia  forms  almost  a  necessary  part  of  the  treatment  in  severe  cases. 
The  local  application  of  the  galvanic  current  is  most  useful.  Various 
surgical  operations,  as  castration,  ligature  of  the  spermatic  artery,  or  of 
the  sj^ermatic  cord,  have  from  time  to  time  been  practised,  and  with 
varying  success. 

Neuealgia  op  the  Bladder  (Cystalgia). 

§  340.  Nem-algia  of  the  bladder  is  not  common  as  an  idiopathic  affection ; 
but  severe  neuralgic  pains  of  the  bladder,  as  the  result  of  the  presence  of 
calculus  or  of  mahgnant  diseases,  are  common.  Paroxysms  of  nem-algic 
pains  in  the  bladder  may,  however,  result  in  women  from  long-continued 
menorrhagia  combined  with  anaemia  (Anstie),  and  it  is  said  sometimes  to 
be  caused  by  malaria. 

Symptoms. — Neuralgia  of  the  bladder  consists  of  severe  paroxysms  of 
pain  seated  at  the  neck  of  the  bladder,  and  accompanied  by  a  frequent 
desire  to  micturate. 

Neuralgia  of  the  Urethra. 

§  341.  Nem-algic  pains  at  times  occur  in  the  urethra  in  the  entire  absence 
of  any  local  cause  or  other  source  of  irritation  to  account  for  them.  They 
occur  most  frequently  in  clironic  diseases  of  the  spinal  cord,  and  more 
especially  as  a  symptom  of  locomotor  ataxy. 


746  ABDOMINAL  PORTION  OF  THE   SYMPATHETIC. 

Neuralgia  of  the  urethra  consists  of  severe  pain  in  the  course  of  the 
urethra  occurring  in  paroxysms,  and  often  attended  by  some  difficulty  in 
voiding  the  urine,  along  with  urgent  desire  to  empty  the  bladder,  probably 
due  to  reflex  spasm  of  the  latter.  The  diagnosis  of  the  affection  must 
depend  partly  upon  the  character  of  the  pains  and  partly  upon  the  absence 
of  any  local  cause  such  as  stricture,  urethritis,  or  the  passage  of  a  calculus 
to  account  for  them. 

Treatment. — The  usual  treatment  of  neuralgia  must  be  adopted  ;  while 
suppositories  of  morphia  passed  into  the  rectum  or  into  the  urethra  itself, 
along  with  hot  fomentations,  form  the  best  local  remedies. 


Part   III.— DISEASES    OF   THE   SPINAL    CORD   AND 
MEDULLA    OBLONGATA. 


CHAPTER    I. 

ANATOMICAL  AND   PHYSIOLOG'iCAL  INTRODUCTION. 

I.— ANATOMY    or   THE    SPINAL    CORD   AND    MEDULLA 
OBLONGATA. 

The  spinal  cord  is  that  part  of  the  cerebro-spinal  axis  which  is 
situated  within  the  vertebral  canal.  It  extends  from  the  margin 
of  the  foramen  magnnm  to  the  lower  part  of  the  body  of  the 
first  lumbar  vertebra ;  it  is  continuous  above  with  the  medulla 
oblongata,  and  ends  below  in  the  filum  terminale.  We  shall 
consider  :  (A),  the  structure  of  the  spinal  membranes  (the  invest- 
ments of  the  medulla  oblongata  being  part  of  the  membranes  of 
the  brain  their  consideration  may  be  deferred  for  the  present) ; 
(B),  the  blood-vessels  of  the  spinal  cord,  medulla  oblongata,  and 
pons;  (C),  the  structure  of  the  spinal  cord  ;  and  (D),  the  struc- 
ture of  the  medulla  oblongata  and  pons. 

(A)  Structure  of  the  Spinal  Membranes. 

The  spinal  cord  is  surrounded  by  a  compound  connective- 
tissue  sheath,  consisting  of  (I.)  the  dura  mater,  (II.)  the 
arachnoid,  and  (III.)  the  pia  mater. 

§  342.  (I.)  The  dura  mater  is,  speaking  roughly,  composed 
of  two  lamelloe,  each  of  which  consists  of  a  layer  of  parallel 
bundles  of  fine  connective-tissue  fibres,  the  bundles  in  the  outer 
being  mainly  longitudinal,  in  the  inner  circular.-^     Flattened, 

'  Key  and  Retzius.  Studien  in  der  Anatomie  des  Nervensystems.  Erste 
Halfte,  1875  (Tab.  L),  p.  1,  et  seq. 


748        ANATOMICAL  AND   PHYSIOLOGICAL   INTKODUCTION. 

more  or  less  branched  cells  lie  between  the  connective-tissue 
bundles  in  spaces  which  communicate  with  one  another,  and 
which  constitute  the  lymph-canalicular  system.  The  inner 
surface  of  the  dura  mater  is  lined  by  a  thin  hyaline  elastic 
membrane,  which  is  covered  by  a  continuous  layer  of  nucleated 
endothelial  plates.  The  outer  surface  is  also  covered  with  a 
continuous  layer  of  endothelium.  The  dura  mater  is  richly 
supplied  with  blood-vessels  and  nerves. 

(II.)  Tlie  arachnoid  sheath  is  a  delicate  membrane,  composed 
of  parallel  bundles  of  connective-tissue  fibres,  longitudinally  dis- 
posed, with  connective -tissue  corpuscles  lying  between  them. 
The  outer  surface  is  covered  by  one  or  two  layers  of  endothelial 
plates,  and  on  the  inner  surface  is  a  fenestrated  layer,  composed 
of  anastomosing,  transversely  disposed  trabecula3  of  connective- 
tissue  fibres,  the  innermost  surface  of  the  membrane  being 
covered  by  a  single  layer  of  endothelial  plates. 

Fig.  128. 


Fig.  128  (after  Key  and  Retzius).  Transverse  Section  of  the  Spinal  Cord,  with  its  Mem- 
branes, in  the  Upper  Dorsal  Region. — Close  on  the  inner  surface  of  the  dura  (A) 
lies  the  arachnoid  (B),  which  is  thrown  into  longitudinal  folds  at  intervals.  In 
the  posterior  subarachnoidal  space  (the  part  behind  the  ligamenta  denticulata, 
G),  the  septum  posticum  (C)  may  be  observed  in  the  middle,  with  its  numerous 
partitions,  along  with  the  subarachnoidal  spaces  which  they  enclose.  The 
septum  becomes  partly  attached  to  the  arachnoid  externally,  and  partly  spreads 
laterally  over  the  inner  surface  of  that  membrane  (D).  The  septum  spreads 
internally  over  the  pial  sheath  as  the  epipial  subarachnoidal  tissue  (E),  forming 
numerous  small  spaces.  Two  vessels  may  be  observed  in  this  epipial  space. 
r,  the  posterior  nerve  roots,  surrounded  by  the  subarachnoidal  membranes. 
The  space  (I)  between  the  latter  membranes  and  the  septum  posticum  is  of 
variable  depth.  K  is  the  space  between  the  posterior  nerve  roots,  with  their 
membranes,  and  the  ligamentum  denticulatum ;  this  space  being  free  from 
membrane  throughout  the  entire  length  of  the  cord,  the  subarachnoidal  fluid 
finds  a  freer  passage  through  it  than  through  any  other  part  of  the  posterior 
subarachnoidal  space.  Anterior  to  the  ligamenta  denticulata  (G),  the  anterior 
subarachnoidal  space  may  be  observed  free  from  membrane.  H,  the  anterior 
nerve  roots. 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION.        749 

(III.)  The  pia  mater  consists  of  an  external  and  internal 
portion.^  The  former  is  composed  of  longitudinal  bundles  of 
connective-tissue  fibres,  and  its  external  surface  is  covered  by 
an  endothelial  layer.  The  internal  portion,  or  intima  pi«,  is  a 
meshwork  of  bundles  of  connective-tissue  fibres,  its  inner  surface 
being  lined  by  a  layer  of  endothelial  cells.  The  pia  mater  con- 
tains numerous  blood-vessels,  which  lie  between  the  external 
and  internal  layers,  whence  they  penetrate  into  the  substance 
of  the  cord,  being  surrounded  by  a  prolongation  of  the  pial 
sheath. 

The  subarachnoidal  tissue  consists  of  a  plexus  of  trabeculse 
of  fibrous  connective  tissue  ensheathed  in  endothelium  and  con- 
taining a  few  elastic  fibres.  It  forms  a  spongy  tissue  between 
the  arachnoidal  and  pial  sheaths,  and  subdivides  the  subarach- 
noidal space  into  numerous  minute  lacunas.  It  is  a  prolongation 
of  the  inner  portion  of  the  arachnoid,  and  its  trabeculse  contain 
larger  and  smaller  blood-vessels. 

The  ligamentum  denticulatum  extends  from  the  foramen 
ovale  magnum  down  to  the  filium  terminale,  and  stretches  like 
a  diaphragm  between  the  arachnoid  and  pial  sheaths  on  each  side 
of  the  cord,  and  between  the  anterior  and  posterior  nerve  roots. 
The  subarachnoidal  space  is  consequently  divided  into  an  anterior 
and  posterior  chamber.  The  ligamentum  denticulatum  consists 
of  trabeculsB  of  connective-tissue  bundles,  the  trabecule  being 
covered  with  endothelium.  The  tissue  passes  into  the  external 
layer  of  the  pia  mater  (Klein). 

Isolated  connective-tissue  trabeculse  also  extend  between  the 
dura  mater  and  arachnoid;  they  are  ensheathed  in  endothelium, 

Fig.  129. 


Fig.  129  (from  Key  and  Eetzius).  Diagram  of  a  Transverse  Section  of  the  Spinal 
Cord  and  its  Membranes,  shoioing  the  natural  size  and  relative  positions  of  the 
cord,  membranes,  and  spaces. 

'  See  Klein  and  Smith.    Atlas  of  Histology.    1880.    p.  91. 


750        ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 

while  blood-vessels  and  nerves  pass  from  the  one  membrane  to 
the  other.  These  trabeculse  are  most  numerous  in  the  posterior 
parts  of  the  cord. 

Between  the  dura  mater  and  arachnoid  is  the  subdural,  and 
between  the  arachnoid  and  pia  mater  is  the  subarachnoidal 
lymph  space.  Neither  of  these  spaces  form  one  open  and  free 
cavity,  inasmuch  as  numerous  connective-tissue  trabeculse  pass 
between  the  dura  mater  and  arachnoid,  and  between  the  latter 
and  pia  mater.  The  two  spaces  do  not,  however,  communicate 
with  one  another. 

The  nerve  roots  receive  a  prolongation  from  both  the  arach- 
noidal and  durai  sheaths,  and  consequently  the  lymph  spaces  of 
the  peripheral  nerves  and  their  ganglia  have  been  injected  from 
the  subarachnoidal  and  subdural  spaces  respectively.^ 

(B)  The  Blood-vessels  of  the  Spixal  Cord,  Medulla  Oblongata, 

AND  Pons. 

The  consideration  of  the  distribution  of  the  blood-vessels  of 
the  spinal  axis  may  be  divided  into,  (i.)  a  general  survey  of  the 
arteries;  (ii.)  the  nutritive  arteries  of  the  spinal  cord;  and  (ill.) 
the  nutritive  arteries  of  the  medulla  oblongata  and  pons. 

(L)    GENERAL  SURVEY  OF  THE  BLOOD-VESSELS  OF  THE  SPINAL  AXIS.  2 

§  343.  The  vertebral  artery  is  the  first  and  largest  branch  of 
the  sub-clavian  artery.  It  arises  from  the  posterior  aspect  of 
the  trunk,  and  ascends  through  the  foramina  in  the  transverse 
processes  of  all  the  cervical  vertebrae,  except  the  last.  It  winds 
backwards  around  the  articulating  process  of  the  atlas,  pierces 
the  dura  mater,  enters  the  skull  through  the  foramen  magnum, 
and  terminates  at  the  lower  border  of  the  pons  Varolii  by  uniting 
with  the  corresponding  vessel  of  the  opposite  side  to  form  the 
basilar  artery. 

The  basilar  aHery  runs  forward  in  the  groove  on  the  anterior 
surface  of  the  pons  Varolii,  and  divides  at  the  anterior  border  of 
the  pons  into  two  terminal  branches,  one  to  either  side. 

I  Key  and  Eetzius.  Nordiskt.  Med.  Arkiv  ,  Bd.  II.,  1870,  IL,  Nr.  26;  and 
Bd.  VI.,  1874,  v.,  Nr.  7.     Abstr.  Virchow's  Jahresb. 

'^See  Duret  (H).  "Sur  la  distribution  des  artferes  nourricieres  du  bulbe  rachi- 
dien."    Archives  de  physiologie,  Tome  V.,  1873,  p.  97. 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.         751 


Branches.— The  branches  of  the  vertebral  and  basilar  artery  are  the 

following : — 

Vertebral  Basilar. 

Lateral  spinal,  Transverse, 

Muscular  branches,  Middle  cerebellar, 

Posterior  meningeal,  Superior  cerebellar, 

Anterior  spinal.  Posterior  cerebral. 
Posterior  spinal. 
Inferior  cerebellar. 

Fig.  130. 


Fig.  130  (after  Duret).     Arteries  of  the  Medulla  Oblongata,  Pons,  and  Inferior 
Surface  of  the  Cerebellum. 

1,  Root  arteries  of  the  spinal  accessory  nerve. 

2,  Anterior  spinal  arteries. 

3,  Arteries  of  the  pneumogastric  and  glosso-pharyngeal  nerves. 

4,  Inferior  arteries  of  the  auditory  and  facial  nerves  (vertebral  branches). 

5,  Hoot  arteries  of  the  sixth  nerve. 

6  and  7,  Arteries  of  the  sub-olivary  fossa. 

8,  Superior  arteries  of  the  auditory  and  facial  nerves  (branches  of  the  middle 

cerebellar  artery). 

9,  Arteries  of  the  trigeminal  nerve. 

10,  Arteries  of  the  hypoglossal  nerve  (branches  of  the  vertebral  and  anterior 

spinal  arteries). 

A,  Inferior  cerebellar  artery. 

B,  Middle  cerebellar  artery. 

C,  Superior  cerebellar  artery. 

D,  Posterior  cerebral  artery. 


752        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

The  lateral  spinal  branches  enter  the  intervertebral  foramina,  and, 
taking  the  course  of  the  roots  of  the  spinal  nerves,  are  distributed  to  the 
spinal  cord  and  vertebrae.  Where  the  vertebral  artery  ciu-ves  round  the 
articular  process  of  the  atlas,  it  gives  off  several  muscular  branches. 

The  posterior  meningeal  arteries  are  small  branches  which  enter  the 
cranium  through  the  foramen  magnum,  to  be  distributed  to  the  dura  mater 
of  the  cerebellar  fossae,  and  to  the  falx  cerebelli. 

Th,e  anterior  spinal  artery  is  a  small  branch  which  unites  with  its  fellow 
of  the  opposite  side,  on  the  front  of  the  medulla  oblongata.     The  artery 

Fig.  131. 


Fig.  131  (af  Cer  Duret).     Arteries  of  the  Pons  and  Medulla. 


1  1',  Anterior  spinal  artery,  the  bulbar 

branches. 

2  2'  2",  Inferior  arteries  of  the  pons. 

3  3",  Median  arteries  of  the  pons. 

4,  Superior  arteries  of  the  pons. 

5,  Posterior    spinal    arteries,    median 

branches. 


A,  Left  vertebral  artery. 

B,  Basilar  artery. 

C,  Middle  cerebellar  artery. 

D,  Superior  cerebellar  artery. 

E,  Posterior  cerebral  artery. 


ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION. 


75: 


formed  by  the  union  of  these  two  vessels  descends  along  the  anterior  asj)ect 
of  the  spinal  cord,  to  which  it  distributes  branches,  and  forms  the  com- 
mencement of  the  anterior  median  artery. 

The.  posterior  spinal  artery  winds  around  the  medulla  oblongata  to 
reach  the  posterior  aspect  of  the  cord,  and  descends  on  either  side  to  the 
Cauda  equina.  It  communicates  very  freely  with  the  spinal  branches  of  the 
intercostal  and  lumbar  arteries,  and  near  its  origin  sends  a  branch  upwards 
to  the  fourth  ventricle. 

The  inferior  cerebellar  arteries  wind  around  the  upper  part  of  the 
medulla  oblongata  to  reach  the  under  surface  of  the  cerebellum,  to  which 
they  are  distributed.  They  pass  between  the  filaments  of  origin  of  the 
hypoglossal  nerve  in  their  course,  and  anastomose  with  the  superior  cere- 
bellar arteries.  Small  branches  derived  from  these  trunks  pass  to  the 
choroid  plexus  of  the  fourth  ventricle. 

The  transverse  branches  of  the  basilar  artery  supply  the  pons  Varolii 
and  adjacent  parts  of  the  brain. 

Fig.  132. 


C--%. 


Fio.  132  (after  Duret).     Distribution  of  the  Arteries  on  the  Floor  of  the  Fourth 

Ventricle. 
A  A',  Posterior  spinal  artery. 
B  B',  Its  p3rraBiidal  branches. 
C  C  C"  C",  Emergence  of  the  median  arteries. 
D  D',  Choroid  plexus  drawn  to  one  side,    (Two  or  three  arteries  may  be  seen  to 

emerge  from  it.) 
E  E'  E"  E'",  Arteries  of  the  restiform  bodies  coming  from  the  inferior  cerebellar 
artery. 


VOL.  I. 


WW 


754        ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION. 


The  middle  cerebellar  artery  arises  from  the  trunk  of  the  basilar,  about 
its  middle.  It  runs  parallel  to  the  transverse  branches,  and  passes  along 
the  middle  peduncle  to  be  distributed  to  the  anterior  part  of  the  under 
surface  of  the  cerebellum.  It  gi^'es  off  a  small  branch,  auditiva  interna, 
which  accompanies  the  auditory  nerve  into  the  meatus  auditorius  internus, 
and  to  the  labyrinth  of  the  car.  The  auditory  branch  is  frequently  derived 
directly  from  the  basilai. 

The  superior  cerebrllar  wteries  wind  around  the  crus  cerebri  on  each 
side,  lying  in  relation  with  the  foiu-th  nerve,  and  are  distributed  to  the 
upper  surface  of  the  cerebellum  anastomosing  with  the  inferior  cerebellar. 
Branches  of  the  superior  cerebellar  arteries  run  inwards  to  supply  the 
valve  of  Vieussens  and  the  posterior  part  of  the  velum. 

Fig.  133. 


Fig.  133  (after  Duret).     Arteries  of  the  Posterior  Part  of  the  MedMa  and  the 

Cerebellum. 
A,  Choroid  plexus.  B,  Choroid  velum.  C,  Posterior  opening, 

forming  a  communication  between  the  fourth  ventricle  and  the  pos- 
terior subarachnoid  space.  D,  Posterior  pyramid. 
1,  Inferior  cerebellar  artery. 

2  2',  Artery  of  the  choroid  plexus. 

3  3  3  3,   Arteries  of  the  choroid  velum.    Some  proceed  to  the  floor  of  the  fourth 

ventricle  ;   they  are  capillary. 

5,  Posterior  spinal  artery, 

6,  Its  ascending  or  pyramidal  branch. 

7,  Its  descending  branch. 

8,  Its  median  branch. 


ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION.        755 

The  ascending  cervical  branch  of  the  inferior  thyroid  artery 
gives  off  one  or  two  branches  (spinal  branches)  which  enter  the 
intervertebral  foramina  along  with  the  cervical  nerves,  and  assist 
in  supplying  the  bodies  of  the  vertebrae  and  the  spinal  cord  and 
its  membranes. 

The  spinal  branches  of  the  aortic  intercostal  arteries  enter 
the  intervertebral  foramina  of  the  dorsal  region,  and  supply  the 
vertebrae,  spinal  cord,  and  membranes. 

The  spinal  branches  of  the  lumbar,  ilio-lumbar,  and  lateral 
sacral  arteries  enter  the  spinal  canal  through  the  intervertebral 
foramina ;  they  are  distributed  like  the  other  spinal  arteries,  and 
anastomose  with  them.  Special  attention  has  been  directed  by 
Dr.  Moxon^  to  the  fact  that  the  spinal  arteries  which  enter  the 
intervertebral  foramina  in  the  cervical  and  upper  dorsal  regions 
pass  almost  horizontally  to  the  cord,  while  those  which  enter  the 
foramina  in  the  lower  dorsal  and  lumbar  regions  have  to  ascend 
a  considerable  distance  before  reaching  it,  those  which  pass 
along  with  the  nerves  of  the  cauda  equina  being  several  inches 
in  length.  The  great  length  of  the  latter  vessels  combined 
with  their  small  calibre  offers  much  resistance  to  the  onward 
flow  of  blood,  and  consequently  the  lower  segments  of  the  cord 
receive  their  blood  supply  at  a  diminished  pressure  and  under 
great  disadvantages. 

(II.)    THE    NUTRITIVE    ARTERIES    OP    THE    SPINAL    C0RD.2 

§  344.  The  anterior  median  artery  gives  off  a  series  of  small  branches, 
wliicli  pass  backwards  in  the  anterior  median  fissure,  and  reach  the  anterior 
commissure,  hence  these  vessels  may  be  called  the  arteries  of  the  anterior 
rnedian  fissm-e  (Fig.  134,  af).  Each  of  these  vessels  on  reaching  the  anterior 
commissure  divides  into  two  main  trunks,  which  enter  the  grey  substance 
of  the  anterior  horns;  these  may  be  called  the  arteries  of  the  anterior 
commissure  (Fig.  134,  ac). 

The  artery  of  the  anterior  commissure  subdivides  into  three  branches, 
which,  from  their  position,  may  respectively  be  named  the  anterior 
i^Fig.  134,  1),  median  {Fig.  134,  1'),  and  posterior  {Fig.  134,  1'')  branches. 
The  anterior  branch  ciu*ves  forwards,  and  is  distributed  to  the  anterior  and 
internal  portion  of  the  grey  substance ;  the  median  is  distributed  to  the 

•  Moxon  (W.).  "Lectures  on  the  influence  of  the  circulation  on  the  nervous 
system."    The  Lancet,  Vol.  L,  1881,  p.  530. 

"Ross  (J.).  "Distribution  of  the  arteries  of  the  spinal  cord."  Brain,  Vol. 
III.,  April,  1880,  p.  80. 


756        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

lateral  portion  of  the  anterior  horn,  while  the  posterior  is  directed  back- 
wards to  the  posterior  horn. 

The  central  artery  also  gives  off  an  anterior  {Fig.  1.34,  2),  median 
{Fig.  134,  2'),  and  posterior  {Fig.  134,  2")  branch,  which  are  distributed 
respectively  to  the  anterior,  lateral,  and  posterior  portions  of  the  grey  sub- 
stance. The  median  branches  of  the  two  main  vessels,  besides  supplying 
the  grey  substance,  are  also  distributed  to  the  pyramidal  tract  of  the  lateral 
column. 

Fig.  134. 


ea  a 


ip'-^i'p- 


Tig.  134  (Young).     Diagram  of  the  Distribution  of  the  Blood-vessels,  and  Grouping 
of  Ganglion  Cells  in  the  Spinal  Cord. 


Anterior  median  artery. 
af.  Arteries  of  the  anterior  median  fis- 
sure. 
ac.  Artery  of  the  anterior  commissure. 

1,  Anterior  branch. 
1',  Median  branch. 
1",  Posterior  branch. 

ca.  Central  artery. 

2,  Anterior  branch. 
2',  Median  branch. 
2",  Posterior  branch. 

pa,  Posterior  root  arteries. 

6  6'  6",  Arteries  of  posterior  horns. 
ia.  Internal  anterior  root  arteiy. 
ea,  External  anterior  root  artery. 

3  3',  Internal  and  external  branch. 


ar,  Antero-lateral  branch. 
4,   Anterior  branch. 
4',  Median  branch. 
4",  Posterior  branch. 
mr,  Median  lateral  artery. 

.5  5',  Anterior  and  posterior  branches, 
pr,  Posterior  lateral  arteries. 
ip,  Internal  posterior  artery. 
mp.  External  posterior  artery. 
g,  Arteries  of  the  column  of  Goll. 
pc,  Artery  of  the  posterior  commissure, 
re,  Vesicular  column  of  Clarke, 
i,  Internal  group  of  cells. 
a,  Anterior  group. 
al,  Antero-lateral  group. 
pi,  Postero-lateral  group. 
c.  Central  group. 
m,  Median  area. 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.        757 

The  posterior  spiiial  artery  {Fig.  134,  pa)  gives  off  branches  which  pass 
by  the  side  of  the  posterior  roots  to  enter  the  grey  substance  of  the  pos- 
terior horns,  where  they  subdivide  into  a  variable  number  of  small  branches 
{Fig.  134,  6  6'  6"),  which  may  be  called  arteries  of  the  posterior  horns.  In 
addition  to  the  vessels  just  described,  a  large  number  pass  from  the  pia 
mater  into  the  substance  of  the  cord,  and  some  of  these  are  so  large  and  so 
constant  as  to  deserve  special  mention ;  two  run  by  the  side  of  the  bundles 
of  fibres  which  constitute  the  anterior  roots  of  the  nerves,  hence  they  may 
be  called  the  anterior  root  arteries.  The  branch  nearest  the  median  fissure 
may  be  called  the  internal  anterior  root  {Fig.  134,  ia),  and  the  other  the 
external  anterior  root  {Fig.  134,  ea)  artery. 

The  internal  anterior  root  artery  {Fig.  134,  ia),  on  entering  the  grey 
substance,  joins  the  anterior  branches  of  the  first  subdivision  of  the  artery 
of  the  anterior  median  fissure  and  of  the  central  artery. 

The  external  .anterior  root  artery  {Fig.  134,  ea),  on  entering  the  grey 
substance,  subdivides  into  two  branches,  the  inner  {Fig.  134,  3)  of  which  is 
distributed  along  with  the  vessels  just  mentioned ;  while  the  outer  branch 
{Fig.  134,  3')  passes  between  what  we  may  call  the  antero-lateral  {Fig. 
134,  al)  and  central  groups  {Fiq.  134,  c)  of  cells. 

A  very  constant  vessel  passes  to  the  grey  substance  from  the  ijia  mater, 
at  the  point  of  junction  of  the  anterior  and  lateral  columns  of  the  cord, 
and  it  may  therefore  be  called  the  antero-lateral  artery  {Fig.  134,  ar).  On 
reaching  the  grey  substance  it  frequently  divides  into  three  branches,  one 
of  which  passes  in  front  {Fig.  134,  ar,  4  4'  4"),  another  behind,  and  another 
into  the  substance  of  the  antero-lateral  group  of  cells.  Another  constant 
vessel  {Fig.  134,  mr)  passes  from  the  lateral  aspect  of  the  cord,  and  on 
reaching  the  grey  substance  it  subdivides  into  two  branches,  the  one  of 
which  passes  in  front  and  the  other  behind  the  postero-lateral  group  of 
cells  {Fig.  134,  pi),  and  this  vessel  may  from  its  position  be  called  the 
median-lateral  artery.  Small  branches  {Fig.  134,  pr)  pass  at  short  intervals 
through  the  posterior  part  of  the  lateral  column,  and,  together  with  the 
median  branches  of  the  first  subdivision  of  the  artery  of  the  anterior 
median  fissure,  and  of  the  central  arteries,  supply  the  posterior  part  of  the 
lateral  columns;  hence  these  vessels  may  be  called  posterior  lateral  arteries. 

Two  vessels  pass  from  the  pia  mater  into  the  substance  of  the  posterior 
column  ]  the  one  nearest  the  posterior  median  fissure,  and  which  may 
therefore  be  called  the  internal  posterior  artery  {Fig.  134,  ip),  passes 
between  the  column  of  GoU  and  the  posterior  root-zone  ;  and  after  passing 
through  about  two-thirds  of  the  depth  of  the  posterior  column,  it  curves 
outwards  to  reach  the  posterior  grey  horn.  The  other  vessel  may  be  named 
the  externud  or  median  posterior  artery  {Fig.  134,  mp) ;  it  passes  into  the 
substance  of  the  posterior  column  at  the  middle  of  the  posterior  root-zone, 
and  on  reaching  about  one-third  the  depth  of  the  posterior  column,  it 
curves  outwards  to  reach  the  posterior  grey  horn,  where  it  terminates. 
Small  vessels  {Fig.  134,  g)  pass  from  the  pia  mater  of  the  posterior  median 
fissure  into  the  substance  of  the  column  of  Goll.     Another  vessel,  which 


758        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


pl'a 


Fig.  135.  Section  of  the  Medulla  Oblongata,  showing  the  Distribution  of  the  Vessels. 

K,  Artery  of  the  Median  Raphe. 

Ill,  Brunches  to  the  formatio  reticularis. 
1',  Branch  to  the  olivary  body. 
1",  Branches  to  the  hypoglossal  nucleus. 

1'",        ,,  ,,      floor  of  the  fourth  ventricle,  and  to  the  internal  inferior 

nuclei  of  the  facial  (if). 
p,  Pyramidal  arteries. 
ar,  Anterior  root  artery  (hypoglossal). 
2',  Branch  to  olivary  body. 

2",  Branches  to  the  formatio  reticularis.     It  terminates  in  branches  to  the 
hypoglossal  nucleus. 
Ir,  Lateral  root  artery  (vagua). 

5,  Branch  to  the  restiform  body  and  the  inner  division  of  the  inferior  cere- 
bellar peduncle. 
5',  Branches  to  the  nucleus  of  the  vagus.      Also  gives  branches  to  the 
ascending  root  of  the  fifth  and  the  formatio  reticularis. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.        759 

may  be  called  the  artery  of  the  posterior  commissure  {Fig.  134,  ^sc),  passes 
from  the  pia  mater  along  the  posterior  margin  of  the  posterior  commissure, 
and  winds  backwards  along  the  internal  edge  of  the  posterior  horn. 

Adamkiewcz  ^  has  also  given  a  minute  description  of  the  distribution 
of  the  vessels  of  the  spinal  cord.  He  distinguishes  (1)  a  centrifugal 
system  corresponding  exactly  with  the  anterior  median  artery,  its  branches 
diverging  and  anastomosing  with  those  of  (2)  the  centripetal  system. 
In  this  he  includes  three  classes  of  vessels  :  (a)  marginal,  small  branches 
from  the  vessels  in  the  pia;  (6)  vessels  of  the  white  substance,  vessels 
running  longitudinally  with  the  nerve  bulbs  and  supplying  them;  (c) 
vessels  of  the  grey  substance,  passing  imbranched  to  the  grey  substance,  and 
there  breaking  up  into  a  capillary  network. 

(III.)  THE  NUTRITIVE  ARTERIES    OP   THE    MEDULLA.   OBLONGATA  AND    PONS. 

§  S4<o.  The  following  arteries,  derived  from  the  basilar,  ver- 
tebral, and  inferior  cerebellar  trunks,  are  distributed  to  the 
medulla  oblongata  and  pons : — 

ala,  The  anterior  lateral  artery  of  the  medulla  oblongata.  It  supplies  branches 
to  the  formatio  reticularis,  olivary  body,  anterior  nucleus  of  the  lateral 
column  {ale),  and  terminates  in  branches  to  the  hypoglossal_  nucleus. 

rnla,  The  middle  lateral  artery  of  the  medulla  oblongata.  It  supplies  branches 
to  the  fo7-matio  reticulans,  the  posterior  nucleus  of  the  lateral  column 
[pic],  and  terminates  in  branches  which  are  distributed  to  the  external 
accessory  nucleus  of  the  facial  (e/). 

pia,  The  posterior  lateral  arteries  of  the  medulla  oblongata.     They  supply  the 
restiform  bodies. 
C,  Central  artery. 

3  3'  3",  Branches  to  the  hypoglossal  and  external  accessory  facial  nuclei. 
mp,  Median  posterior  artery. 

4  4'  4",  Branches  to  the  external  accessory  facial  and  pneumogastric  nuclei. 
ep,  External  posterior  artery.     It  supplies  branches  to  the  internal  division  of 

the  inferior  peduncle  of  the  cerebellum  and  restiform  body. 
i.  Internal  group  of  cells  of  the  hypoglossal  nucleus. 
al,  Antero-lateral        ,,  ,, 

pi,  Postero-lateral       ,,  ,, 

a.  Anterior  ,,  ,, 

ale.  Anterior  nucleus  of  the  lateral  column, 
pic,  Posterior       ,,  ,, 

VIII,  Inferior  portion  of  the  posterior  median  acoustic  nucleus. 
if,  Internal  accessory  facial  nuclei. 
ef.  External  accessory  facial  nucleus. 
/,  Fasciculus  rotundus. 
xn,  Hypoglossal  nerve. 
X,  Pneumogastric  nerve. 
G,  Column  of  GoU. 

pr.  Posterior  root-zone.     The  direct  cerebellar  tract  forms  a  thin  band  lymg  ex- 
ternal to  the  column  of  Goll  and  posterior  root-zone. 
en,  Clavate  nucleus. 
tn,  Triangular  nucleus. 
0,  Olivary  body. 

po,  Parolivary  body. 
np,  Nucleus  of  the  pyramid. 
pn.  Nucleus  of  the  arciform  fibres. 
P,  Anterior  pyramid. 

1  Adamkiewcz.  Transactions  International  Medical  Congress.  London.  188L 
Vol  L,p.  155. 


760        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

(1)  The  Root  Arteries. — These  arteries  are  directed  laterally  towards 
the  roots  of  the  nerves  ;  they  subdivide  into  an  ascending  branch,  which  is 
directed  towards  the  nuclei  of  origin  of  the  nerves,  and  a  descending  branch 
which  descends  towards  the  periphery. 

(a)  Anterior  Root  Arteries  {Fig.  135,  ar). 

(i.)  The  arteries  of  the  hypoglossal  nerve  are  derived  from  both 

the  anterior  spinal  and  vertebral  arteries, 
(ii.)  The  arteries  of  the  sixth  nerve  are  derived  from  the  basilar, 
(iii.)  The  arteries  of  the  third  nerve  are  derived  from  the  trunk  of 

the  basilar  near  its  termination. 

(6)  Lateral  Root  Arteries  {Fig.  135,  Ir). 

(i.)  The  arteries  of  the  spinal  accessory  nerve  are  derived  from 
the  inferior  cerebellar  and  vertebral  arteries. 

(ii.)  The  arteries  of  the  pneumogastric  and  glosso-pharyngeal 
nerves  arise  from  the  vertebral  artery. 

(iii.)  The  arteries  of  the  auditory,  facial,  and  portio  intermedia 
(nerve  of  Wrisberg)  are  derived  from  the  vertebral  a  little 
before  its  termination,  and  from  a  branch  of  the  basilar. 
Branches  may  also  descend  perpendicularly  from  the  middle 
cerebellar  artery. 

(iv.)  The  artery  of  the  trigeminus  is  comparatively  large  and 
constant,  and  is  derived  directly  from  the  basilar  about  its 
middle.  Another  branch  is  derived  from  the  middle  cere- 
bellar artery. 

(v.)  The  fourth  nerve,  as  well  as  the  optic  and  olfactory  nerves, 
receives  its  arterial  supply  from  the  branches  of  the  circle 
of  WilUs. 

(2)  Arteries  op  the  Median  Raphe  {Fig.  135,  R). 

(a)  Bulbar  arteries  derived  from  the  anterior  spinal  artery  {Fig.  131,  1). 
(6)  Inferior  arteries  of  the  pons  derived  from  the  lower  end  of  the 

basilar  {Fig.  131,  2  2'  2"). 
(c)  Median  arteries  of  the  pons,  derived  from  the  trunk  of  the  basilar 

{Fig.  131,  3  3"). 
{d)  Superior  arteries  of  the  pons,  derived  from  the  superior  end  of  the 

basilar  {Fig.  131,  4). 

The  annexed  diagram  {Fig.  136)  shows  that  a  double  row  of  vessels 
enter  the  raph^,  the  vessels  on  each  side  of  the  middle  line  entering  at 
diflferent  levels.  A  vertical  section  of  the  olivary  body  shows  that  the 
vessels  enter  the  hilus  in  a  similar  manner  ;  so  that  the  branches  from  the 
anterior  root  artery  and  the  artery  of  the  raphd  are  never  seen  in  the  same 
horizontal  section  as  represented  in  Fig.  135. 

(3)  The  Lateral  Arteries  op  the  Medulla  Oblongata. 

(a)  Anterior  lateral  artery  {Fig.  135,  ala)  passes  into  the  substance  of 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


761 


the  medulla  behind  the  olivary  body.  It  gives  branches  to  the 
olivary  body,  the  anterior  lateral  nucleus,  and  terminates  between 
the  groups  of  ganglion  cells  of  the  hypoglossal  nerve. 

(b)  Middle  lateral  artery  {Fig.  135,  mla)  passes  into  the  substance  of 

the  medulla  in  front  of  the  restiform  body.  It  gives  branches  to 
the  posterior  lateral  nucleus,  and  terminates  between  the  group  of 
cells  which  give  origin  to  the  lateral  mixed  system  of  nei'ves. 

(c)  The  posterior  lateral  arteries  {Fig.  135,  pla)  enter  the  substance  of 

the  restiform  body  behind  the  roots  of  origin  of  the  mixed  lateral 
system  of  nerves. 

(4)  The  Central  Artery  {Fig.  135,  c)  of  the  medulla  oblongata  is  a 
continuation  of  the  central  artery  of  the  spinal  cord.  It  subdivides  into 
internal  middle,  and  external  branches  {Fig.  135,  3  3'  3*)?  which  are 
distributed  between  the  groups  of  cells  of  the  hypoglossal  nucleus. 

(5)  The  Median  Posterior  Artery  {Fig.  135,  mp)  enters  the  sub- 
stance of  the  medulla  oblongata  on  the  floor  of  the  fourth  ventricle.  It  is 
probably  derived  from  the  choroid  plexus.  It  is  mainly  distributed  to  the 
groups  of  cells  which  give  origin  to  the  nerves  of  the  lateral  mixed  system. 

(6)  The  External  Posterior  Artery  {Fig.  135,  '.p)  enters  the  sub- 
stance of  the  medulla  at  the  junction  of  the  grey  substance  with  the 
restiform  body. 

Fig.  136. 


Fig.  136  (after  Henle).  Vertical  Section  of  RapM  of  the  Medulla  Oblongata,  showing 
the  entrance  of  the  vessels. 


762         ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

(C)  The  Structure  of  the  Spinal  Cord. 

The  spinal  cord  is  composed  of  a  series  of  segments,  which  are 
placed  one  above  the  other,  and  each  of  which  gives  origin  to  a 
pair  of  nerves.  In  considering  the  anatomy  of  the  cord  we  shall 
briefly  describe  (l.)  the  structure  of  a  segment  of  the  cord — say 
the  first  dorsal  segment ;  and  (ii.)  the  development  of  the  cord, 
making  in  these  two  divisions  special  reference  to  the  disposition 
of  the  various  parts  of  the  cord  on  transverse  section.  The  study 
of  the  development  of  the  cord  will  enable  us  to  analyse  the 
anatomical  divisions,  and  thus  to  subdivide  the  cord  into  embryo- 
logical  systems,  and  we  shall  then  be  in  a  position  to  describe 
(ill.)  the  distribution  of  these  systems  throughout  the  cord  in 
its  longitudinal  extent. 

(I.)    THE  structure  OP  A  SPINAL  SEGMENT. 

The  spinal  cord  is  seen  to  be  imperfectly  divided  into  segments 
or  columns  by  superficial  longitudinal  fissures,  the  best  marked 
of  these  being  the  anterior  and  posterior  median  fissures  {Fig. 
137,  1  and  2),  which  divide  the  cord  into  symmetrical  lateral 
halves.  The  anterior  median  fissure  penetrates  one-third  of  the 
thickness  of  the  cord,  and  increases  in  depth  towards  the  lower 
part  of  the  latter ;  it  contains  a  fold  of  pia  mater  and  numerous 
blood-vessels.  The  posterior  median  fissure  is  more  manifest  in 
the  upper  part  of  the  cord,  but  throughout  its  greatest  extent  it 

Fig.  137. 


Fig.  137  (after  Allen  Thomson,  from  Quain).  The  Anterior  Surface  of  the  Spinal 
Segment,  the  anterior  root  of  the  right  side  being  divided.  — I,  The  anterior 
median  fissure  ;  2,  Posterior  median  fissure ;  3,  Anterior  lateral  depression,  over 
which  the  anterior  nerve-roots  are  seen  to  spread  ;  4,  Posterior  lateral  groove 
into  which  the  posterior  roots  are  seen  to  sink ;  5,  Anterior  roots  passing  the 
ganglion ;  5',  The  anterior  root  divided ;  6,  The  posterior  roots,  the  fibres  of 
which  pass  into  the  ganglion,  6' ;  7,  The  united  or  compound  nerve  •,  7',  The 
posterior  primary  branch  seems  to  be  derived  in  part  from  the  anterior  and  in 
part  from  the  posterior  root. 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.        763 

is  a  mere  septum  of  connective  tissue  and  blood-vessels  which 
passes  in  nearly  to  the  centre  of  the  cord.  The  anterior  and 
posterior  median  fissures  are  separated  from  one  another,  and 
the  lateral  halves  of  the  cord  are  united  by  the  anterior  white 
and  the  posterior  grey  commissure,  having  between  them  the 
central  canal  with  the  tissue  immediately  surrounding  it. 

In  addition  to  these  fissures  superficial  depression  may  be 
observed  along  the  lines  of  attachment  of  the  anterior  and  pos- 
terior roots,  which  are  respectively  named  the  anterior  lateral, 
and  the  posterior  lateral  fissures  {Fig.  137,  3  and  4).  These 
fissures  divide  each  lateral  half  of  the  cord  into  three  columns, 
the  portion  between  the  anterior  median  and  the  anterior  lateral 
fissures  being  named  the  ,anterior  column,  that  between  the 
anterior  and  posterior  lateral  fissures  the  lateral  column,  and 
that  between  the  posterior  lateral  and  the  posterior  median 
fissure  the  posterior  column. 

In  its  internal  structure  the  spinal  cord  consists — (1)  of  a 
framework,  with  (2)  nervous  grey,  and  (3)  white  matter  em- 
bedded in  it. 

(1)  The  Framework. 

§  346.  The  framework  consists  of  (a)  connective-tissue  pro- 
cesses, and  (b)  neuroglia. 

{a)  Connective-tissue  Processes. — Processes  of  fibrous  con- 
nective tissue  pass  from  the  intima  pise  into  the  anterior  fissure, 
and  at  different  points  of  the  circumference  of  the  cord,  where 
they  form  septa,  which  divide  the  white  columns  of  the  cord  into 
segments.  Along  these  prolongations  of  the  intima  pise  the 
blood-vessels  of  the  cord  pass  in  perivascular  sheaths. 

(6)  Neuroglia. — The  chief  part  of  the  framework  consists  of  a 
semi-fluid  substance  named  the  neuroglia-matrix.  This  sub- 
stance presents  a  granular  aspect  under  certain  reagents,  but 
is  homogeneous  in  the  fresh  condition.  Numerous  minute 
fibrils,  which ,  anastomose  with  one  another  in  a  network,  are 
embedded  in  this  substance.  These  fibrils  have  a  longitudinal 
direction,  except  in  the  septa,  where  they  form  transverse  net- 
works, and  in  the  grey  substance,  where  they  extend  uniformly 
in  all  directions  (Klein).  Flat,  branched,  nucleated  connective- 
tissue  corpuscles  are  found  in  connection  with  the  network  of 


764        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


the  neuroglia  fibrils.  The  neuroglia,  therefore,  is  composed  of 
neuroglia-matrix,  neuroglia  fibrils,  and  branched  cells,  the  latter 
being  named  Deiter's  cells  {Fig.  139). 

Authors  are  by  no  means  agreed  as  to  the  structure  of  the 
neuroglia.  According  to  Kolliker,^  it  is  made  up  of  a  network, 
formed  by  the  anastomoses  of  branched  processes  of  connective- 
tissue  corpuscles.  In  some  cases  the  cells  themselves  have  dis- 
appeared, leaving  only  the  network  of  processes.  The  fibrous 
plexus  of  the  neuroglia  is  regarded  by  Gerlach^  as  belonging  to 
elastic  tissue,  both  on  account  of  its  resemblance  to  such  tissue 
and  its  great  resistance  to  the  action  of  alkalies.  The  cellular 
elements  of  the  neuroglia  he  regards  as  connective -tissue  cells, 
modified  by  being  present  in  various  stages  of  development.  He 
believes,  indeed,  that  the  neuroglia  is  a  peculiarly  modified 
form  of  connective-tissue;  that  its  matrix  is  finely  granular,  or 


Fig.  1.38. 


*    3     8 


Fig.  138  (after  Henle).  Diagram  of  the  Spinal  Cord  and  its  Memhranes.~l,  the 
dura  mater ;  2,  the  arachnoid,  and  (3)  the  pia  mater ;  4,  the  cortical  layer  of  the 
neuroglia. 

'  KoUiker.     Handbuch  der  gewebelehre.     5th  Auil.    267. 

^  Gerlach  (J.).    Strieker's  Manual  of  Histology.    Ait.  "The  spinal  cord."    New 
Syd.  Soc,  Vol.  II.,  1872,  p.  333, 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.        765 

structureless  instead  of  being  fibrillated;  and  that  it  is  traversed 
in  all  directions  by  plexuses  of  fine  elastic  fibres.  By  other 
authorities^  the  neuroglia  is  resjarded  as  of  the  same  nature  as 
the  intercellular  substance  of  an  epithelium,  and  its  cells  are 
considered  to  be  analogous  with  the  branched  migratory  cells 
which  are  sometimes  found  in  stratified  epithelium. 

Distribution  of  the  Neuroglia. — Neuroglia,  with  little  or  no  nervous 
elements,  is  found  in  the  following  parts : — 

(i.)  On  the  external  surface  of  the  cord,  where  it  forms  a  perij)heral  crust 
beneath  the  intima  pise,  the  latter  being  easily  separated  from  the  former. 

(ii.)  In  the  septa  which  j)ass  between  different  sections  of  the  white 
matter,  the  posterior  fissure  being,  indeed,  only  a  septxun  of  this  kind 
(Klein). 

(iii.)  It  forms  the  ground  substance  of  the  anterior  and  posterior  nerve 
roots. 

(iv.)  A  layer  of  neuroglia  of  considerable  thickness  surroimds  the  epi- 
thehal  lining  of  the  central  canal,  named  the  central  grey  nucleus  of 
Kolliker.  This  is  an  unfortunate  name,  inasmuch  as  it  is  apt  to  lead  the 
reader  to  believe  that  this  portion  of  the  grey  substance  corresponds  with 
the  nuclei  of  the  nerve  fibres,  whereas  it  is  destitute  of  nerve  elements. 

(v.)  A  pecuHar  form  of  neuroglia  is  found  in  the  posterior  portion  of  the 
posterior  grey  horns,  forming  the  substantia  gelatinosa  of  Eolando. 

(2j  The  Grey  Substance. 

§  347.  The  grey  substance  occupies  the  central  parts  of  the 
cord  in  the  well-known  shape  of  an  H.  The  median  part  contains 

Fig.  139. 


Fig.  1.39  (after  Henle\    Deiter's  Cells, 
See  Quain's  Elements  of  Anatomy.    9th  Edit.     Vol.  II.,  1882,  p.  149. 


766        ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION. 

the  central  canal,  and  the  "  central  grey  nucleus "  of  Kolliker, 
the  anterior  grey  and  white  commissures  lying  in  front  and  the 
posterior  commissure  behind  it.  The  lateral  parts  or  columns 
consist  of  an  anterior,  middle,  and  posterior  part,  the  first  of 
these  representing  the  anterior,  and  the  last  the  -posterior  grey 
horn;  the  middle  portion  on  each  side  of  the  central  canal 
consists  of  the  vesicular  column  of  Clarke,  and  what  may  be 
called  the  central  column.  The  central  grey  nucleus  of  Kolliker 
may  indeed  be  regarded  as  a  portion  of  the  central  column. 

The  grey  matter  consists  of  a  {a)  matrix  of  neuroglia,  (6) 
nerve  fibres,  and  (c)  ganglion  cells. 

(a)  The  neuroglia  of  the  grey  matter  is  similar  to  that  of 
the  white  {vide  sup.).  It  is  looser  in  texture  and  more  spongy 
in  the  central  grey  column  than  in  either  the  anterior  or  pos- 
terior horns,  and  in  this  situation  it  also  contains  a  relatively 
larger  number  of  Deiter's  cells. 

(6)  The  nerve  fibres  of  the  grey  matter  are  of  different  kinds. 
The  great  bulk  of  the  grey  matter  is  composed  of  a  minute  and 
dense  network  of  fine  fibrils,  named  Gerlach's^  nerve  network, 
formed  by  anastomoses  of  processes  of  branched  cells.  The  nerve 
network  surrounding  the  central  grey  nucleus  of  Kolliker  is  less 
dense  than  in  other  parts.  The  branched  processes  of  the 
ganglion  cell  attach  themselves  to  Gerlach's  nerve  network ; 
while  the  unbranched  processes  pass  into  a  medullated  nerve 
fibre  of  the  anterior  root.  The  cells  of  the  posterior  horns  are 
not  directly  connected  with  any  nerve  fibres,  but  anastomose 
with  them  indirectly  through  Gerlach's  nerve  network. 

(c)  The  ganglion  cells  of  the  anterior  horns  are  relatively 
large,  branched  cells,  containing  in  some  animals  masses  of 
yellow  pigment  (§  13).  These  cells  are  surrounded  by  a  lymph 
space,  through  which  the  processes  of  the  cell  pass.  The 
ganglion  cells  of  the  posterior  horns  are  much  smaller  and  less 
branched  than  those  of  the  anterior  horns.  Some  of  the  latter 
appear  spindle-shaped,  but  each  extremity  is  branched  into 
several  processes. 

The  ganglion  cells  of  the  anterior  horns  are  arranged  in  groups 
which  are  pretty  constant  for  the  same  portions  of  the  cord, 
although  the  arrangement  varies  considerably  when  sections  at 

'  Gerlach.    Op.  cit.,  p.  353. 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.        767 

differeat  elevations  are  compared.  A  diagram  of  the  topographical 
distribution  of  these  groups  is  given  in  Fig.  134  Beginning  at 
the  posterior  and  lateral  aspect  of  the  anterior  horn,  a  group  is 
observed  which  from  its  position  is  called  the  postero-lateral 
group  {pi).  It  is  bounded  behind  by  the  posterior  and  in  front 
by  the  anterior  twig  of  the  median  branch  of  the  central  artery; 
while  on  its  external  aspect  it  receives  branches  from  the  median 
lateral  artery,  one  of  which  passes  behind  and  another  in  front  of 
it.  Anterior  to  this  group  is  another,  which  from  its  position  is 
called  the  antero-lateral  group  (al).  On  its  external  aspect  the 
group  receives  branches  from  the  anterior  lateral  artery,  one  of 
these  passing  behind  and  another  in  front  of  it,  while  a  median 
branch  of  the  artery  may  often  be  seen  to  pass  into  its  sub- 
stance. A  branch  from  the  external  anterior  root  artery  winds 
round  its  inner  border  to  gain  the  posterior  aspect ;  while  the 
anterior  branch  of  the  central  artery  passes  along  its  internal 
and  anterior  aspects. 

It  has  already  been  mentioned  that  the  internal  and  external 
anterior  root  arteries,  on  reaching  the  grey  substance,  divide  into 
two  branches ;  and  the  external  branch  of  the  former  and  internal 
of  the  latter  converge  so  as  to  meet  at  a  point  like  the  limbs  of 
the  letter  Y.  In  the  small  area  of  grey  matter  which  lies  between 
these  vessels  several  distinct  cells  are  so  constantly  observed  as 
to  deserve  a  special  name.  These  cells  may  from  their  position 
be  called  the  anterior  group  (a).  Another  group  of  large  cells, 
which  may  be  called  the  internal  group  (i),  is  bounded  an- 
teriorly and  internally  by  white  substance,  and  on  the  external 
aspect  by  the  anterior  branch  of  the  first  subdivision  of  the 
artery  of  the  anterior  median  fissure.  Another  group  of  cells 
may  be  observed  towards  the  centre  of  the  anterior  horns,  and  it 
may  therefore  be  termed  the  central  group  (c).  It  is  bounded  in 
front  and  on  its  internal  and  external  borders  by  the  external 
and  internal  branches  of  the  external  anterior  root  artery ;  and 
behind  and  also  on  its  internal  border  by  the  median  and  an- 
terior branches  of  the  central  artery.  A  very  important  area  lies 
between  the  internal  group  on  the  one  hand  and  the  antero- 
lateral and  central  groups  on  the  other,  while  the  anterior  group 
passes  into  its  anterior  border,  like  a  small  wedge,  so  as  to  divide 
it  into  the  form  of  the  letter  Y.     The  cells  of  this  median  area 


768        ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 

(m)  are  much  smaller  than  those  of  the  other  groups,  and  the 
area  itself  is  exceedingly  vascular,  being  supplied  by  the  two  an- 
terior root  arteries,  the  anterior  branch  of  the  first  division  of  the 
artery  of  the  anterior  median  fissure,  and  the  anterior  branch  of 
the  central  artery.  A  final  group  of  cells  lies  near  the  internal 
border  of  the  posterior  grey  horn  near  the  posterior  commissure 
called  the  vesicular  column  of  Clarke  (vg).  We  must  again 
direct  attention  to  the  fact  that  Fig.  134)  is  only  a  diagram  ;  and 
although  it  is  more  like  the  upper  part  of  the  lumbar  and  lower 
portion  of  the  cervical  enlargemeats  than  any  other  part  of  the 
cord,  yet  it  is  not  a  strictly  accurate  representation  of  any  one 
section.  The  distribution  of  these  groups  at  various  elevations 
of  the  cord  will  be  better  understood  after  the  history  of  the 
development  of  the  grey  substance  has  been  sketched, 

(3)  The  White  Substance. 

§  848,  The  white  substance  is  composed  of  medullated  nerve 
fibres,  by  far  the  greater  number  being  arranged  in  a  longitudinal 
direction.  A.  vertical  section  of  the  spinal  cord  is  represented  in 
Fig.  140,  showing  the  longitudinal  disposition  of  the  fibres  in 
the  anterior  and  lateral  columns.  Each  nerve  fibre  possesses  an 
axis  cylinder,  and  a  medullary  sheath,  but  there  is  no  definite 
evidence  of  the  presence  of  a  sheath  of  Schwann,  or  of  nerve 

Fig.  140. 


Fig.  140(afterHenle).—n,  Anterior  column;  Cga,  Anterior  grey  horn ;  Fa,  Lateral 
column ;  Ca,  Posterior  grey  horn. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.        769 

corpuscles,  as  in  the  medullated  fibres  of  the  cerebro-spinal 
nerves.  The  nerve  fibres  are  embedded  in  neuroglia  as  pre- 
viously described;  they  vary  much  in  size,  some  being  broad, 
some  of  medium  size,  while  others  are  very  fine. 

The  white  matter  also  contains  nerve  fibres  that  have 
an  oblique  or  horizontal  direction.  The  following  may  be 
distinguished : — 

(i.)  The  fibres  of  the  posterior  roots  pass  into  the  grey  matter  of  the 
posterior  horns  as  horizontal  fibres.  These  fibres  on  entering  the  cord 
spread  out  laterally  in  the  form  of  a  fan,  so  that  an  external  fasciculus,  an 
internal  fasciculus,  and  a  median  portion  may  be  distinguished.  The  fibres 
of  the  external  fasciculus  wind  forwards  round  the  external  margin  of  the 
posterior  horn,  and  at  least  some  of  them  pass  forwards  through  the 
anterior  commissure,  a  few  even  passing  between  the  longitudinal  fibres  of 
the  anterior  column,  so  as  to  reach  the  internal  and  anterior  groups  of 
ganglion  cells  of  the  anterior  grey  horn  of  the  opposite  side  {Fig.  152,  p"). 
The  fibres  of  the  internal  fasciculus  pass  between  the  longitudinal  fibres  of 
the  posterior  root-zone  to  gain  the  posterior  horn  {Fig.  152,  pr').  Some  of 
them  then  wind  round  the  vesicular  column  of  Clarke,  but  it  is  not  known 
whether  they  are  connected  with  the  cells  of  that  column.  A  few  of  these 
fibres  appear  to  pass  behind  the  vesicular  column  of  Clarke  and  to  decussate 
with  the  corresponding  fibres  of  the  opposite  side  in  the  posterior  com- 
missure. The  median  portion  of  the  posterior  root  enters  the  white  matter 
of  the  posterior  column,  and  its  fibres  pass  for  a  longer  or  shorter  distance 
in  a  longitudinal  direction,  either  upwards  or  downwards,  before  joining  the 
posterior  grey  horns. 

(ii.)  The  medullated  nerve  fibres  of  the  anterior  nerve  roots  pass  in  an 
oblique  direction  from  the  grey  matter  of  the  anterior  horns  through  the 
white  matter. 

(iii.)  The  anterior  commissure  is  said  by  Gerlach^  to  be  composed  of 
medullated  nerve  fibres  that  pass  from  the  grey  matter  of  the  anterior  horn 
of  one  side  into  the  white  matter  of  the  anterior  tract  of  the  opposite  side. 
Some  of  the  fibres,  however,  pass  from  the  anterior  horn  of  one  side  to  the 
pyramidal  tract  of  the  opposite  side,  while  others,  as  already  described,  pass 
from  the  internal  fasciculus  of  the  posterior  roots  of  one  side  to  the  anterior 
grey  horn  of  the  opposite  side. 

(iv.)  Medullated  nerve  fibres  emerge  from  the  sides  of  the  grey  matter  of 
the  anterior  horns,  and  after  a  short  course  enter  the  white  matter  of  the 
lateral  tracts  (Klein). 

(v.)  Nerve  fibres  emerge  from  the  posterior  grey  horns,  and  after  a  longer 
or  shorter  horizontal  course  enter  the  white  matter  of  the  posterior 
column.  2  It  is  probable  that  they  leave  the  posterior  tracts  again  as  the 
nerve  fibres  of  the  posterior  roots  (Klein). 

1  Gerlach  (J.).     Op.  cit.,  p.  340.  »  Gerlach.     Op.  cit ,  p.  341. 

VOL.  I.  XX 


770        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

(vi,)  Fibres  emerge  from  the  cells  of  the  vesicular  column  of  Clarke, 
which  pass  obUquely  outwards  and  upwards  to  enter  the  direct  cerebellar 
tract  (Flechsig).  These  fibres  form  round  bundles  at  the  junction  of  the 
grey  substance  and  the  lateral  column,  and  are  cut  transversely  in  hori- 
zontal sections.  These  bundles  are  represented  in  Figs,  152  to  156  as  dark 
round  spots  near  the  formatio  reticularis  (fr). 


(II.)  DEVELOPMENT  OF  THE   SPINAL  CORD. 

§  349.  The  parts  which  subsequently  correspond  to  the  an- 
terior grey  horns  are  the  first  portions  of  the  cord  to  be  developed. 
These  are  soon  succeeded  by  lateral  masses,  and  somewhat  later 
by  the  posterior  horns.  The  anterior  grey  commissure  is  then 
formed,  and  this  is  soon  followed  by  the  development  of  the 
posterior  commissure,  and  it  is  only  at  a  considerably  later  period 
that  the  white  commissure  appears.  When  the  rudiment  of  the 
cord  has  closed,  so  as  to  form  a  tube,  it  is  seen  to  be  somewhat 
oval  on  section,  and  at  this  period  it  consists  almost  entirely  of 
grey  substance. 

The  grey  substance  is  at  first  composed  of  small  round  cells, 
not  much  larger  than  lymphoid  corpuscles,  with  a  distinct 
nucleus,  and  no  difference  can  be  detected  between  one  portion 
and  another ;  the  whole  is  simple  and  indefinite  in  its  structure. 
A  section  of  the  cord  at  the  third  month  of  embryonic  life 
{Fig.  141)  shows  that  the  central  canal  has  contracted  to  a  small 
oval  opening,  lined  by  a  columnar  epithelium,  while  the  grey 
substance  has  assumed  the  general  outline  characteristic  of  the 
grey  substance  of  the  adult  cord.  The  grey  substance  is  also 
surrounded  by  a  mantle  of  white  substance,  and  we  shall,  there- 
fore, describe  the  development  (1)  of  the  grey  and  (2)  of  the 
white  substance. 

(1)  Development  of  the  Grey  Substance  of  the  Spinal  Cord. 

For  the  sake  of  convenience  we  shall  divide  our  account  of  the 
evolution  of  the  grey  substance  of  the  spinal  cord  into  that  of 
the  development  of  (a)  the  anterior  horns,  (6)  the  accessory 
nerve  nuclei  of  the  spinal  cord,  (c)   the  posterior  grey  horns, 

(d)  the  central  column  with  the  vesicular  column  of  Clarke,  and 

(e)  the  neuroglia. 


ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION. 


771 


Fig.  141. 


(a)  Tlie  Anterior  Grey  Horns. 

§  350.  Tlie  most  noticeable  feature  about  the  grey  substance  at  the  third 
month  {Fig.  141)  is  that  the  anterior  grey  horns  are  distinctly  differentiated 
from  the  posterior  horns,  not  simply  in  their  general  outhne,  but  in  their 
intimate  structure.  The  groups  of  ganglion  cells  are  now  beginning  to  be 
distinctly  recognisable.  Of  these,  the 
antero- lateral  group  is  the  most  ad- 
vanced in  its  development.  Large, 
mostly  round,  cells,  with  a  distinct 
nucleus,  are  observed  embedded  in  the 
embryonic  tissue ;  but  the  cells  have 
not  yet  assumed  distinct  processes. 
The  small  internal  group  is  also  well 
represented  by  several  distinct  large 
cells,  but  the  cells  are  more  elongated, 
and  not  quite  so  large  or  so  distinct  as 
in  the  antero-lateral  group.  A  few  cells 
may  be  observed  in  the  anterior  group. 
The  postero-lateral  group  is  represented 
by  four  or  five  large  round  cells,  but 
the  central  group  is  not  yet  represented. 
The  areas  in  which  the  median  and 
central  groups  are  subsequently  deve- 
loped, and  the  area  which  separates 
the  antero-lateral  and  postero-lateral 
groups,  are  composed  entirely  of  embryonic  tissue,  with  smaU  round  cells. 
The  vesicular  column  of  Clarke  can  also  be  distinguished  at  this  period, 
by  a  sHght  increase  in  the  size  of  the  cells  in  comparison  with  those  of  the 
surrounding  tissue,  but  the  group  does  not  appear  in  the  portion  of  the 
cord  from  which  this  section  was  taken. 

A  still  further  advance  in  development  is  recognisable  at  the  end  of  the 
fifth  month  of  embryonic  life  {Figs.  142  and  143).  The  cells  of  the  antero- 
lateral group  have  not  only  increased  still  further  in  size,  but  their  pro- 
cesses are  now  well  developed  (Fig.  143,  1),  and  each  may  be  seen  to  lie  in 
a  distinct  cavity.  Those  of  the  anterior  and  internal  groups  are  also  well 
developed,  and  the  same  may  be  said  with  respect  to  the  cells  of  the  centre 
of  the  postero-lateral  group ;  and  even  those  of  the  central  group  are  fairly 
well  developed,  although  only  two  or  three  of  them  have  as  yet  developed 
processes.  The  area  in  which  the  median  group  is  subsequently  developed, 
and  the  margins  of  the  postero-lateral  and  central  groups  still  consist  of 
embryonic  tissue.  The  larger  cells  of  these  areas  are  represented  in 
Fig.  143,  2.  The  section  represented  in  Fig.  142  was  taken  from  the 
middle  of  the  cervical  enlargement,  and  the  vesicular  column  of  Clarke  is 
not  represented;  but  the  cells  of  this  column  are  fairly  well  developed 
at  the  fifth  month  in  the  lower  end  of  the  cervical  enlargement  and  in 


Fig.  141.  Section  from  the  middle  of 
the  Cervical  Enlargement  of  the 
Spinal  Cord  at  the  Third  Month 
of  Embryonic  Life. — tJ,  Central 
canal.  The  other  letters  indicate 
the  same  as  the  corresponding 
letters  in  Fig.  134. 


772        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

the  dorsal  region  and  upper  end  of  the  lumbar  enlargement.  The  section 
represented  in  Fig.  143  was  taken  from  the  middle  of  the  lumbar  enlarge- 
ment, and  no  trace  of  the  postero-lateral  group  could  be  discovered ;  but  in 
the  upper  portion  of  the  lumbar  enlargement  it  occupies  a  similar  position 
to  that  which  it  occupies  in  the  cendcal  enlargement,  as  represented  in 
Fig.  142.  The  vesicular  column  of  Clarke  does  not  appear  in  the  greater 
part  of  the  lumbar  enlargement. 

Fig.  143. 
Fig.  142. 


Figs.  142  and  143  (Young).  Sections  of  Spinal  Cord  of  a  Five-Months  Human 
Embrtjo,  from  the  middle  of  the  cervical  and  lumbar  enlargements  respectively. — 
i,  internal ;  a,  anterior ;  al,  antero-lateral ;  pi,  postero-lateral,  c,  central,  and 
m,  median  groups  of  ganglion  cells  :  1,  ganglion  cell  cf  the  centre  of  the  antero- 
lateral group ;  2,  ganglion  cell  of  median  group. 


The  ganglion  cells  of  the  various  gToups  have  become  still  further  deve- 
loped at  the  ninth  month  {Figs.  144  and  145)  ;  while  by  the  development 
of  caudate  cells  in  the  central  and  postero-lateral  groups  the  various 
groups  have  become  so  approximated  as  not  to  be  so  distinctly  recognisable 
from  each  other  as  they  were  at  the  fifth  month  of  embryonic  hfe.  The 
section  represented  in  Fig,  144  was  taken  from  the  middle  of  the  lumbar 
enlargement,  and  the  postero-lateral  group  is  not  so  well  represented  as  it 
is  in  the  upper  part  of  the  lumbar  region.  The  median  area  now  contains 
distinct  ganglion  cells  instead  of  consisting  entirely  of  embryonic  tissue. 
These  cells  are,  however,  not  much  larger  than  those  of  the  antero-lateral 
group  at  the  third  month  ;  while  they  are  by  no  means  so  well  developed 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


773 


as  those  of  the  latter  at  the  fifth  month.  The  cells  of  the  median  group 
are  small,  angular  masses  with  a  distinct  nucleus,  but  only  a  relatively 
small  number  of  these  have  developed  processes.  It  is  not  necessary  to 
say  much  at  present  with  respect  to  the  adult  cord.  The  most  noticeable 
feature  in  which  the  cervical  and  lumbar  enlargements  of  the  adult  cord 
differ  from  the  corresponding  parts  of  the  cord  of  a  nine-months  embryo  is 
in  the  fact  that  the  ganglion  cells  of  the  median  group  have  developed  pro- 
cesses like  those  of  the  other  groups.  The  cells  of  the  median  group, 
however,  especially  in  the  cervical  enlargement,  are  much  smaller  than 
those  of  the  other  groups,  and  this  area  is  more  transparent  on  section 
than  those  containing  the  earlier-formed  groups  of  cells. 

The  relationship  which  the  developing  cells  bear  to  the  distribution  of 
the  blood-vessels  is  exceedingly  interesting.  The  earlier-developed  cells 
appear  to  be  thrust  further  and  further  away  from  the  vessels  as  develop- 
ment advances.  The  postero-lateral  group,  for  instance,  first  shows  itself 
by  the  development  of  four  or  five  large  cells,  which  appear  about  the 
centre  of  the  spot  in  which  the  completed  group  is  subsequently  situated ; 
and,  as  ganglion  cell  after  ganglion  cell  becomes  developed  around  this 
centre,  the  area  becomes  increased  in  size  by  the  growth  of  additional 
embryonic  tissue  around  the  circumference  of  the  group  in  the  part  which 


Fig.  144. 


Fig.  145. 


Figs.  144  and  145  (Young).  Sections  of  Spinal  Cord  of  a  Nine-Months  Human 
Embryo,  from  the  middle  of  the  lumbar  and  cervical  enlargements  respec- 
tively.—  A,  anterior,  and  P,  posterior  horns.  The  small  letters  indicate  the 
same  as  in  Figs.  142  and  143.  The  normal  size  of  the  section  from  wrhich  the 
drawing  was  made  is  shown  above  each  figure. 


774 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


is  in  relation  with  the  arterioles  {Fig.  134).  The  ganglion  cells  of  the 
centre  of  the  group  are  the  first  to  be  developed,  and  the  group  increases  in 
size  by  the  gradual  development  of  new  cells  around  the  central  ones,  the 
marginal  ceUs  being  thus  the  last  to  be  formed.  Similar  remarks  apply 
to  the  ganglion  cells  of  the  central  group,  as  well  as  to  the  antero-lateral, 
anterior,  and  internal  groups,  except  that  the  last  three  groups,  instead 
of  being  surroimded  on  all  sides  by  grey  substance,  are  on  one  of  their 
sides  in  contact  with  white  substance. 


(6)  Tlie  Accessory  Nerve  Nuclei  of  the  Spinal  Cord. 

§  351.  (1)  Median  Area. — The  comparatively  late  period  in  the  develop- 
ment of  the  cord  at  which  the  ganglion  cells  of  the  median  area  of  the  anterior 
horns  assume  processes  shows  that  this  area  must  be  regarded  as  an  accessory 
structure  (§  33).  The  relatively  large  size  of  this  area  in  the  cervical,  as 
compared  with  the  lumbar  enlargement,  shows  that  it  is  a  much  more  im- 
portant structiu"e  in  the  former  than  the  latter  region.  In  the  fifth  month 
of  embryonic  hfe  the  median  area  is  not  larger  in  the  cervical  than  in  the 
lumbar  region,  as  shown  in  Figs.  142  and  143,  where  it  will  be  seen  that  there 
is  scarcely  any  difierence  in  the  general  outhne  of  the  anterior  horns  in  the 
sections  from  the  middle  of  the  cervical  and  lumbar  enlargements  respec- 
tively. In  the  embryo  of  the  ninth  month,  however,  the  median  area  in 
the  cervical  is  decidedly  larger  than  in  the  lumbar  enlargement  {Figs.  144 
and  145),  and  consequently  the  anterior  grey  horn  in  the  former  region  is 


Fig.  146. 


Fig.  147. 


I-H— -1/ 


Figs  146  and  147  i  Young).  Sections  of  the  Adult  Spinal  Cord  from  the  middle  of  the 
Lumbar  and  Cervical  Enlargements  resj^cctireli/.—The  letters  indicate  the  same 
as  those  in  Figs.  142  and  143. 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION. 


775 


extended  laterally  to  make  room  for  this  area.  The  relative  increase  in  the 
size  of  the  median  area  in  the  cervical  enlargement  of  the  human  adult 
cord,  as  compared  with  that  of  the  lumbar  enlargement,  is  still  more 
marked  than  in  the  cord  of  a  nine-months  embryo,  as  may  be  seen  in 
Figs.  146  and  147,  where  the  median  area  occupies  a  large  space,  and  the 
lateral  outgrowth  of  the  anterior  grey  horn  of  the  cervical  region  is  very 
decided. 

On  observing  the  large  relative  size  of  the  median  area  in  the  cervical 
enlargement  of  the  adult  human  cord,  as  compared  with  that  of  the  lumbar 
enlargement,  and  even  as  compared  with  that  of  the  cervical  enlargement 
of  the  cord  of  the  embryo,  it  occurred  to  me  that  this  area  might  not 
possess  any  relative  importance  in  the  cervical  enlargement  of  the  spinal 
cord  in  animals.  In  order  to  test  this  conclusion  I  applied  to  Mr.  Larmuth, 
of  the  Owens  College,  whose  beautiful  sections  of  the  spinal  cord  are  well 
known  in  Manchester,  and  asked  him  if  he  would  be  kind  enough  to  let  me 
have  sections  of  the  lumbar  and  cervical  enlargements,  as  well  as  from  the 
middle  of  the  dorsal  region  and  the  upper  portion  of  the  cervical  region  of 
the  spinal  cord  of  the  ox.  Mr.  Larmuth,  in  kindly  consenting  to  let  me 
have  what  I  wanted,  volunteered  the  statement  that  it  was  quite  unneces- 
sary to  have  a  section  of  both  the  cervical  and  lumbar  regions,  as  the  two 

Fig.  148. 


Fig.  148  (Young).    Section  of  Cervical  Enlargement  of  Calf.— The  letters  indicate 
the  same  as  Fig.  142. 


776        ANATOMICAL   AND  PHYSIOLOGICAL   INTEODUCTION. 

were  so  alike  as  to  be  indistinguisliable,  and  both  were  like  tbe  lumbar 
enlargement  of  the  human  cord.  This  was,  to  a  large  extent,  the  very  fact 
I  was  in  search  of.  I  have  had  an  opportunity  since  that  time  of  examining 
these  sections  more  minutely.  A  section  from  the  cervical  enlargement 
of  a  calf  is  represented  in  Fig.  148,  and  it  will  be  at  once  seen  that  the 
general  outline  of  the  grey  substance  is  very  like  that  of  the  grey  substance 
of  the  lumbar  enlargement  in  man,  and  the  median  area  occupies  a  still 
smaller  area  in  the  former  than  in  the  latter.  The  median  area,  indeed, 
can  scarcely  be  said  to  exist  in  the  spinal  cord  of  the  calf,  and  this  is  also 
true  with  respect  to  the  cord  of  the  ox. 

(2)  The,  medio-lateral  area  lies  between  the  antero-lateral  and  postero- 
lateral groups  of  ganghon  cells,  and  it  will  be  hereafter  seen  that  it  is  a 
very  important  structure  in  the  dorsal  and  upper  cervical  regions  of  the 
cord  {Figs.  157  and  158,  ml).  The  cells  of  this  area  are  not  well  developed 
at  the  ninth  month  of  embryonic  life  in  these  regions  of  the  cord,  and  it  is 
entirely  unrepresented  in  the  spinal  cords  of  the  ox  and  dog. 

We  have  jxist  noticed  that  the  cells  of  the  median  and  medio-lateral 
areas  are  not  only  developed  at  a  comparatively  late  period  of  embryonic 
life,  but  that  they  are  also  much  smaller  in  size  than  those  of  the  other 
groups  of  the  anterior  horns.  It  might,  therefore,  be  concluded  that  the 
size  of  a  ganglion  cell  may  be  accepted  as  a  true  test  of -the  time  at  which 
it  began  to  develop.  This  test  can,  however,  be  relied  upon  only  within 
certain  very  narrow  limits.  The  cells  at  the  margins  of  the  postero-lateral 
group  in  the  lumbar  and  cervical  enlargements  are  nearly  if  not  quite  as 
large  as  those  of  the  centre  of  the  group,  although  the  latter  began  to 
develop  at  a  much  earlier  period  than  the  former;  while  the  cells  of  the 
nuclei  of  origin  of  the  third  and  fourth  nerves  are  small,  although  they 
have  begim  to  develop  at  a  comparatively  early  period.  The  size  of  the 
cell  may  be  accepted  as  a  rough  test  of  its  age  during  the  period  of  develop- 
ment, and  no  longer,  just  as  the  size  of  a  growing  human  being  may  be 
accepted  as  a  rough  test  of  age  matil  the  adult  condition  is  attained,  when 
it  ceases  to  be  a  test  any  longer.  The  size  of  the  ganglion  cells  of  the  anterior 
horns  of  the  cord  of  the  adult  appears  to  depend  mainly  if  not  entirely 
upon  the  size  of  the  muscle  over  whose  function  it  presides;  hence  the 
cells  of  the  nuclei  of  the  third  and  fourth  nerves  are  small,  while  the 
greater  number  of  the  cells  of  the  cervical  enlargement  are  large,  and  those 
of  the  lumbar  enlargement  are  still  larger.  It  frequently  happens  that  the 
later-developed  cells  of  the  cord  are  small  in  the  adult  condition,  but  this 
is  because  the  most  special  muscular  adjustments  are  effected  by  the  con- 
tractions of  small  muscles. 


(c)  Development  of  the  Posterior  Grey  Horns. 

§  352.  The  development  of  the  posterior  horns  appears  to  proceed  on  a 
different  principle  from  that  of  the  anterior  horns.  The  vessel  which  is 
mainly  distributed  to  the  posterior  horn  passes  into  it  through  the  centre  of 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.        777 

the  posterior  roots  of  the  nerves,  and  the  development  of  new  substance 
proceeds  mainly  in  the  centre  of  the  horn,  so  that  the  older-formed  tissue  is 
pushed  out  laterally.  The  central  portion  of  the  horn  consists  of  what  is 
called  the  substantia  gelatinosa,  and  is  made  up  in  large  part  of  neuroglia 
and  fibrils,  in  which  medium-sized  ganglion  cells  are  embedded.  The 
lateral  portions  of  the  horn  contain  well-formed  and  thicker  nerve  fibres. 
The  most  internal  of  these  fibres  pass  through  the  posterior  root-zones  in 
order  to  gain  access  to  the  posterior  grey  horns,  and  these  are  called  the 
inner  radicular  fasciculus  (Charcot).  The  outer  radicular  fasciculus  passes 
along  the  outer  margin  of  the  posterior  horn,  and  between  it  and  the  pyra- 
midal tract  of  the  same  side.  It  is  therefore  probable  that  the  inner  and 
outer  radicular  fasciculi  contain  the  earlier-formed  afferent  fibres,  and  that 
consequently  they  preside  over  the  earlier-formed  and  most  fundamental 
functions. 


(d)  Development  of  the  Central  Grey  Column. 

§  353.  The  central  grey  column  appears  to  grow  mainly  round  the  central 
artery  as  a  centre.  The  portion  which  immediately  surrounds  the  central 
canal  consists  almost  entirely  of  neuroglia;  but  the  anterior  and  lateral 
portions  contain,  in  addition,  nerve  fibrils  and  scattered  ganglion  cells,  the 
latter  being  much  smaller  and  not  so  distinctly  caudate  as  those  of  the 
anterior  horns.  This  portion  of  the  grey  substance  contains  a  relatively 
large  number  of  Deiter's  cells,  and  the  neuroglia  is  much  more  spongy  than 
in  the  anterior  and  posterior  horns.  The  posterior  and  inner  part  of  the 
central  column  contains  a  group  of  large  caudate  cells — the  vesicular 
column  of  Clarke.  This  group  lies  close  to  the  internal  border  of  the  pos- 
terior horn,  near  the  posterior  commissm-e.  It  consists  of  neuroglia,  nerve 
fibres,  and  gangUon  cells,  the  latter  of  which  are  bipolar,  or  at  least  not  so 
distinctly  caudate  as  those  of  the  anterior  horn.  The  neuroglia  in  which 
the  cells  are  embedded  is  more  dense  and  compact  than  that  of  the  remain- 
ing portion  of  the  central  column,  being  in  this  respect  similar  to  the 
neuroglia  surrounding  the  cells  of  the  groups  of  the  anterior  horns. 

With  the  exception  of  the  vesicular  column  of  Clarke,  the  central 
column  appears  to  be  the  embryonic  portion  of  the  grey  substance,  the 
portion  adjoining  the  central  canal  being  the  last  formed,  and  consisting  of 
scarcely  anything  but  neuroglia.  As  a  new  layer  of  tissue  grows  around 
the  canal  the  central  opening  becomes  smaller  and  smaller,  and  the  earlier- 
formed  layers  are  displaced  away  from  the  centre.  The  later-formed  parts 
of  the  anterior  and  posterior  horns  grow  at  the  expense  of  the  central 
column.  But  the  portion  subtracted  from  the  central  column  by  each 
increment  superadded  to  the  anterior  and  posterior  horns  is  replaced  by 
the  growth  of  a  new  layer  of  tissue  around  the  central  canal.  The  cells  of 
the  central  column  do  not  develop  until  a  late  period  of  embryonic  life,  and 
they  may  therefore  be  regarded  as  cells  superadded,  in  the  course  of  evolu- 


tion, to  those  of  the  anterior  and  posterior  hra-ns,  and  of  the  vesicular 


pera^ded,  ii 
ior  hOTns, 


778        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

column  of  Clarke,  and  rendered  necessary  by  newly-acquired  complications 
of  movement.  The  group  of  cells  which  I  have  described  as  the  median 
group  of  the  anterior  horn  may,  indeed,  be  regarded  as  an  anterior  out- 
growth of  the  central  column,  its  relatively  large  size  in  the  cervical  region 
being  rendered  necessary  by  the  complicated  movements  of  the  hand.  In 
addition  to  the  ganglion  cells  and  fibres  belonging  to  the  central  column 
itself,  it  transmits  a  large  number  of  intercommunicating  fibres. 

(e)  The  Neuroglia. 

§  354.  So  far  we  have  spoken  only  of  the  development  of  the  ganglion  cells, 
but  we  must  now  briefly  refer  to  that  of  the  neuroglia.  In  the  early  weeks 
of  foetal  life  the  neuroglia  consists  of  small  round  nucleated  cells,  or  rather 
of  a  nucleus  surrounded  by  a  layer  of  soft  protoplasm,  and  with  scarcely  a 
trace  of  basis  substance.  As  development  advances,  the  protoplasm  con- 
tracts round  the  nuclei,  and  the  latter  become  embedded  in  a  fibrillated, 
some  say  granular  or  homogeneous  basis  substance.  The  neuroglia  becomes 
denser  and  more  compact  in  proportion  as  it  acquires  more  and  more  of  the 
biisis  substance  and  loses  its  cellular  character.  This  change  does  not  occur  in 
every  part  of  the  grey  substance  at  the  same  time.'  Speaking  broadly, 
the  neuroglia  assumes  a  fibrillated  texture  in  the  very  portions  in  which  the 
gangUon  cells  are  earliest  developed ;  while  it  maintains  its  embryonic  con- 
dition in  the  margins  of  the  groups  of  ganglion  cells  of  the  anterior  horns 
and  along  the  line  of  the  blood-vessels.  When  a  section  of  the  adult 
cord  is  held  up  to  the  light  the  groups  of  large  ganglion  cells  may  be  seen 
as  dark  spots  intercepting  the  light,  and  strongly  contrasting  with  the 
transparency  of  the  median  area  and  of  the  margins  of  the  antero-lateral 
and  postero-lateral  groups  along  the  lines  of  the  vessels.  The  transparent 
l)ortion  also  embraces  the  anterior  and  posterior  grey  commissures  and  the 
central  column  of  the  grey  substance  as  far  back  as  the  substantia  gelati- 
nosa,  with  the  exception  of  the  area  occupied  by  the  vesicular  column  of 
Clarke.  The  transparency  of  the  area  just  described  is  no  doubt  due  in 
some  measure  to  the  fact  that  the  small  ganglion  cells  themselves  are  more 
transparent  than  the  large  ganglion  cells,  but  it  is  also  in  great  measure 
due  to  the  loose  and  spongy  character  of  the  neuroglia  in  the  former  areas 
as  compared  with  the  compact  and  fibrillated  texture  of  the  neuroglia 
surrounding  the  ganglion  cells  of  the  earlier-developed  groups.  The  trans- 
parency is  increased  by  the  fact  that  the  larger  vessels  of  the  anterior  horns 
pass  along  the  transparent  areas,  while  only  the  smaller  vessels  pass  into 
the  substance  of  the  earlier-developed  groups.  Many  authorities  believe 
that  the  neiu-oglia  is  a  modified  connective  tissue  (§  346),  and  that  it  is 
consequently  derived  from  the  mesoblastic  layer  of  the  embryo  ;  while 
others  believe  that  it  is  of  the  same  nature  as  the  intercellular  substance 
of  an  epithelium,  and  that  it  is  therefore  derived,  like  the  ependyma,  from 
the  epiblastic  layer  of  the  embryo.^ 

'  See  Quain's  Elements  of  Anatomy.    Ninth  Edit.    Vol.  XL,  1882,  p.  149. 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 


779 


(2)  Development  of  the  White  Substance  of  the  Cord. 

The  study  of  the  evolution  of  the  white  substance  of  the  cord 
enables  us  to  divide  it  into  embryological  systems,  but  instead 
of  describing  the  growth  of  each  of  these  separately  we  shall 
divide  our  subject  into :  (a),  general  remarks  on  the  develop- 
ment of  the  white  substance ;  and  (6),  special  remarks  on  the 
development  of  the  accessory  portions. 


Fig.  149. 


{a)  General  Remarks  on  the  Development  of  the  White  Substance. 

§  355.  The  white  substance  is  formed  on  the  surface  of  the  deeper  grey 
substance.  Soon  after  the  rudiment  of  the  cord  has  closed  posteriorly,  the 
tube  formed  is  seen  to  be  somewhat  oval  on  section.  At  this  period  the 
cord  consists  almost  entirely  of  grey  matter ;  and  by  the  appearance  of 
lateral  slits  each  lateral  half  becomes  imperfectly  divided  into  two  parts, 
the  anterior  and  posterior.  lu  the  human  embryo  a  zone  of  white  sub- 
stance appears  towards  the  end  of  the  first  month  on  the  exterior  of  each 
of  these  parts  ;  and  these  may  respectively  be  called  the  anterior  and 
posterior  root- zones  {Fig.  149,  a,  p).  The  anterior  portions  of  what  are 
afterwards  the  lateral  columns  of  the  cord  develop  as  parts  of  the  anterior 
root-zones,  but  the  posterior  portions  do  not  begin  to  develop  until  about 
two  weeks  later.  The  portions  last  developed  appear  to  belong  to  the 
posterior  root-zones,  and  join  them  in  the  medulla  to  form  the  restiform 
bodies ;  and  Flechsig  thinks  that 
they  pass  directly  to  the  cortex  of 
the  cerebelliun,  hence  they  may  be 
called  the  direct  cerebellar  fibres  of 
the  lateral  columns.^ 

At  the  end  of  the  eighth  week, 
then,  the  grey  substance  of  the  cord 
in  the  human  embryo  is  covered 
anteriorly,  posteriorly,  and  laterally 
by  a  layer  of  white  substance  ;  at 
this  period  very  remarkable  changes 
take  place.  Two  bundles  of  longitu- 
dinal fibres,  one  for  each  side,  are 
intercalated  between  the  direct  cere- 
bellar fibres  of  the  lateral  columns  and 
the  posterior  horns  of  grey  matter. 
These  bundles  on  being  traced  up- 
wards are  found  to  pass  forwards  at 


*  riechsig  (P. ).  Die  Leitungsbahnen 
icci  Gehim  und  Riickenmark  des  Men- 
schen.    Leipzig,  1876.    p.  178  et  seq. 


Fig.  149  (from  KoUiker).  Transverse 
Section  of  the  Cervical  Part  of  the 
Spinal  Cord  of  a  Human  Embryo  of 
six  loeeks.  — c,  Central  canal ;  e,  e',  Its 
epithelial  lining ;  g,  Grey  substance ; 
ar,  Anterior  roots ;  pr.  Posterior 
roots ;  a,  Anterior  root-zones ;  p. 
Posterior  root-zones. 


780        ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION. 

the  lower  end  of  the  medulla,  and  after  decussating  with  one  another 
they  push  aside  the  anterior  columns,  and  form  the  inner  and  larger 
portion  of  the  anterior  pyramids  of  the  medulla ;  hence  the  fibres  may 
be  called  the  lateral  pyramidal  tracts  {Fig.  150,  P,  P').  About  the 
same  time  analogous  formations  appear  in  the  anterior  columns,  one  on 
each  side  of  the  median  fissure  which  separates  the  anterior  root- 
zones.  These  bundles  are  very  variable  in  size  and  form,  but  are  gene- 
rally wedge-shaped  or  elliptical ;  they  form  the  outer  and  lesser  portion 
of  the  anterior  pyramids  of  the  medulla,  but  do  not  decussate  with  one 
another.  They  have  been  called  the  columns  of  Tiirck,  or  of  Lockhart 
Clarke ;  and  they  may  also  be  called  the  anterior  pyramidal  tracts 
{Fig.  150,  T).  At  the  same  period  at  which  these  bundles  begin  to 
develop,  somewhat  similar  formations  appear  between  the  posterior  root- 
zones,  one  on  each  side  of  the  posterior  median  fissure,  and  these  are  called 
the  columns  of  Goll  or  the  postero-median  columns  {Fig.  150,  G).  The 
anterior  white  commissm-e  {Figs.  152  to  156,  ao)  also  appears  at  the  same 
time,  that  is,  about  the  eighth  week.  A  most  important  point  to  notice  in 
connection  with  the  development  of  the  white  substance  is  that  the  fibres 
when  first  developed  are  destitute  of  a  medullary  sheath,  and  only  become 
meduUated  at  a  later  period  of  development.  The  law  of  development  already 
stated  might,  indeed,  have  led  us  to  anticipate  that  such  would  be  the  case. 
A  correlated  fact  is  that  the  fibres  of  the  bimdles  which  are  first  formed 
develop  a  medullary  sheath  at  a  time  when  the  fibres  of  the  later-formed 
bundles  are  non-medullated.      When  the  cord  of  a  human  embryo  is 

Fig.  150. 


/  a7i 


Fig.  150.  Cord  of  Human  Embryo  at  five  months.— ah,  ah',  anterior  horns  of  grey 
substance ;  ph,  ph',  posterior  horns  of  grey  substance  ;  ar,  ar',  anterior  root- 
zones  ;  pr,  pr',  posterior  root-zones  ;  P,  P',  pyramidal  fibres  of  lateral  columns  ; 
T,  columns  of  Tiirck ;  G,  columns  of  Goll ;  dc,  dc',  direct  cerebellar  fibres ; 
c,  anterior  commissure. 


ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 


781 


examined  at  the  end  of  the  fifth  month  it  will  be  found  that  the  pyramidal 
fibres  of  the  lateral  columns,  the  fibres  of  the  columns  of  Tiirck  and  of  the 
columns  of  GoU,  are  non-medullated  ;  while  the  fibres  of  the  anterior  and 
posterior  root-zones,  and  the  cerebellar  fibres  of  the  lateral  columns,  are 
medullated.  When  a  transverse  section  of  the  cord  is  examined  in  glycerine 
after  hardening  in  chromic  acid,  the  bundles  composed  of  the  non- 
medullated  fibres  will  be  found  to  transmit  the  light  more  readily  than 
those  composed  of  the  mediillated  fibres,  so  that  the  section  in  the  cervical 
region  of  the  cord  of  a  human  embryo  at  the  fifth  month  presents  the 
appearances  represented  in  Fig.  150.  Even  when  examined  by  the  naked 
eye  after  hardening  in  chromic  acid  the  portions  composed  of  non-medul- 
lated fibres  are  seen  to  be  of  a  much  darker  colour  than  those  constituted  of 
medullated  fibres  ;  the  former  also  become  much  more  deeply  stained  with 
carmine  than  the  latter.  The  bundles  composed  of  the  non-medullated 
fibi-es  are,  indeed,  to  the  naked  eye  and  in  their  reactions  to  staining  fluids, 
more  like  the  gi'ey  than  the  white  substance  of  the  adult  cord. 


(6)  Special  Remarks  on  the  Development  of  the  Accessory  Portions. 

§  356.  Inasmuch  as  the  greater  part  of  the  fibres  of  the  anterior 
and  posterior  root-zones,  as  well  as  those  of  the  direct  cerebellar  tract, 
are  medullated  as  early  as  the  fifth 
month  of  embryonic  hfe,  it  may  be 
presumed  that  all  of  them  are  fvilly 
developed  at  birth.  The  case,  however, 
is  different  with  regard  to  the  fibres  of 
the  pyramidal  tract,  some  of  them 
being  meduUated  and  fuUy  developed 
at  the  ninth  month  of  embryonic  life, 
while  others  are  not.  The  fibres  of  the 
columns  of  GoU  are  probably  also  not 
all  fully  developed  at  birth.  The  fibres 
of  the  pyramidal  tract  in  the  cord  are 
separated  by  the  septa  of  neuroglia 
and  the  branching  vessels  into  small 
lozenge-shaped  spaces  {Fig.  151).  The 
later-formed  fibres  appear  to  insinuate 
themselves  from  above  downwards  along 
the  margins  of  these  spaces,  so  that  the 
earher-formed  fibres  occupy  their  cen- 
tres, the  older  being  therefore  further 

removed   from   the   blood-vessels  than  Fig.  151.     Transv&se  Section  of  a 

J.X,     „               £1             Tj.            u                   J  wortion  of   the    Pyramidal   Tract 

the  younger  fibres.     It  may  be  assiuned  l^agnified.-l,  Fibres  of  large  dia- 

that  the  earher-formed   fibres  connect  meter ;  2,  fibres  of  small  diameter ; 

the  cortex  of  the  brain  with  the  earlier-  J^.S^.^^ft  tt*Strl  ar- 

formed  or  fundamental  ganglion  cells  of  tery  of  the  spina  cord. 


782        ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION. 

the  anterior  horns,  while  the  later-formed  fibres  connect  the  cortex  with 
the  accessory  cells.  What  has  already  been  said  with  regard  to  the  size 
of  the  ganglion  cells  as  a  test  of  the  stage  of  development  of  the  cell  is 
equally  true  with  respect  to  the  diameter  of  the  meduUated  fibres.  The 
diameter  of  these  fibres  may  be  accepted  as  a  rough  test  of  the  age 
of  the  fibres   during  the   period  of  development,  but  no  longer.     It  is 


Fig.  152. 


ar 


Fig,  152.  Middle  of  Lumhar  Enlargement.  Section  of  Spinal  Cord  from  the  middle 
of  the  Lumbar  Enlargement. — A  P,  anterior  and  pcisterior  grey  cornua  respec- 
tively ;  SG,  substantia  gelatinosa ;  cc,  central  canal ;  ac,  pc,  anterior  and 
posterior  commissnre  respectively;  G,  column  of  Goll;  pr,  posterior  root-zone; 
p,  posterior  root ;  p',  external  radicular  fasciculus ;  p'r,  internal  radicular  fasci- 
culus; a,  a,  a,  anterior  roots;  ar,  ar\  anterior  root-zone;  fr,  formatio  reticu- 
laris ;  pt,  pyramidal  tract ; .  T,  column  of  Tiirck. 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 


783 


very  probable  that  the  small  medullated  fibres  of  the  pyramidal  tract 
connect  together  the  smaU  cells  of  the  anterior  horns  and  relatively 
small  cells  in  the  cortex  of  the  brain ;  while  on  the  contrary  the  thick 
fibres  connect  the  large  ganglion  cells  of  the  anterior  horns  and  large 
cells  of  the  cortex.  The  largest  cells  of  the  spinal  cord,  for  instance,  are 
found  in  the  lumbar  region,  and  the  largest  in  the  cortex  of  the  brain  in 
the  paracentral  lobule — the  centre  of  the  movements  of  the  leg— and  it  is 
probable  that  these  cells  are  connected  with  each  other  by  thick  fibres.  We 
have  already  seen  that,  as  a  rule,  the  accessory  are  smaller  than  the  funda- 
mental ganglion  cells  of  the  anterior  horns,  and  it  may  therefore  be  inferred 
that  the  accessory  fibres  of  the  pyramidal  tract  are  as  a  rule  smaller  than 
the  fundamental  ones.  The  smaller  fibres  are  found  in  greater  mmibers  in 
the  internal  and  posterior  part  of  the  lateral  column,  the  portion  of  the 
white  column  which  adjoins  the  grey  substance.  At  this  spot  the  septa  of 
connective  tissue  are  larger,  the  neuroglia  is  more  spongy,  and  the  lozenge- 
shaped  spaces  already  described  {Fig.  151)  are  more  distinctly  marked 
than  in  the  more  external  layers  of  the  white  substance.  ThQ  formatio 
reticularis  of  the  spinal  cord  appears  indeed  to  owe  its  structural  peculiari- 
ties mainly  to  the  fact  that  it  consists  in  great  part  of  longitudinal  fibres 
of  small  diameter  separated  into  bundles  by  comparatively  thick  septa  of 

Fig.  153. 


Fig.  153.    Lower  End  of  Dorsal  Region.— T,  column  of  Tiirck  ;  dc,  direct  cerebellar 
tract.   The  other  letters  indicate  the  same  as  the  correspouding  ones  in  Fig.  152, 


784 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION. 


loose  neuroglia.  This  portion  of  the  cord  also  transmits  fibres  whicti  issue 
from  the  grey  substance  to  ascend  in  the  pyramidal  tract,  and  from  the 
vesicular  column  of  Clarke  to  piass  out  to  the  direct  cerebellar  tract.  But 
the  longitudinal  fibres  of  small  diameter,  which  are  so  abundant  in  this 
portion  of  the  cord,  would  appear  to  belong  to  the  accessory  portion  of  the 
pyramidal  tract.  Indeed,  the  spongy  character  of  the  neuroglia  and  the 
vascularity  of  this  area  render  it  peculiarly  adajjted  for  the  growth  of  new 
fibres.  The  fibres  of  the  columns  of  Goll  are  also  separated  by  the  distri- 
bution of  the  blood-vessels  and  sejjta  of  connective  tissue  into  lozenge- 
shaped  spaces.  The  fibres  at  the  margins  of  these  spaces  are  not  meduUated 
at  nine  months  of  embryonic  life,  and  they  are  as  a  rule  less  in  diameter  in 
th#  adult  cord  than  the  fibres  which  occupy  the  centres  of  the  spaces. 
These  small  fibres  must  therefore  be  regarded  as  belonging  to  the  accessory 
system.  The  fibres  of  the  posterior  root-zones  are  smaller  than  those  of 
the  anterior  and  lateral  columns,  with  the  exception  of  some  of  the 
accessory  fibres  of  the  pyramidal  tract.  The  reason  of  this  appears  to 
be  that  the  fibres  of  the  posterior  root-zones  connect  the  cells  of  the 
posterior  horns  with  each  other,  and  the  latter  being  themselves  small 
the  intercommunicating  fibres  are  aLso  small 


ac 


^   ^^-^^P^ 


/"'    p'v  \( 

Fig.  154.   Upper  End  of  Dorsal  Reyinn. 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


785 


(III.)    THE  DISTRIBUTION  OP  THE   EMBRYOLOGICAL  SYSTEMS   THROUGHOUT 
THE  CORD  IN   ITS  LONGITUDINAL  EXTENT. 

The  distribution  of  the  grey  matter  as  a  whole  throughout 
the  vertical  exteut  of  the  cord  does  not  require  separate  con- 
sideration, and  we  shall  therefore  describe  the  longitudinal 
distribution  (1)  of  the  groups  of  ganglion  cells,  and  (2)  of  the 
embryological  systems  of  the  white  substance. 

(1)  Longitudinal  Distribution  of  the   Groups  of  Ganglion 

Cells. 
§  857.  The  remarks  which  have   hitherto   been   made  refer 
particularly  to   the   development  of  the   lumbar  and    cervical 
enlargements  of  the  cord  ;  but  a  few  words  must  now  be  said 

Fig.  155. 


VOL.  L 


Fift.  155.    Middle  of  Cervical  Enlargement. 
YY 


786        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

with  respect  to  the  distribution  of  the  various  groups  of  ganglion 
cells  in  the  other  portions  of  the  cord.  The  grey  substance  of 
the  dorsal  region  is  represented  in  Fig.  158,  where  it  will  be 
seen  that  the  most  anterior  portion  of  the  anterior  horn  is 
occupied  by  three  small  groups  of  large  ganglion  cells.  These 
groups  cannot  be  so  distinctly  distinguished  in  every  section  as 
they  were  in  the  one  from  which  this  drawing  was  taken;  but 
indications  of  such  a  division  may  be  found  in  most  sections. 
These  groups  appear  to  correspond  to  the  internal,  antero-lateral, 
and  central  groups  in  the  cervical  and  lumbar  regions ;  while 
the  median  group  of  small  cells,  which  is  so  conspicuous  in  the 
cervical   enlargement,   is   wholly   unrepresented   in   the   dorsal 


Fig.  156.  Section  on  a  level  with  the  Second  Cervical  ^erve.—sa.  Spinal  accessory 
nerve.  The  other  letters  indicate  the  same  as  the  corresponding  ones  in 
Figs.  152  and  153i 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


787 


region.  A  very  remarkable  feature  of  the  grey  substance  of  the 
dorsal  region  is  a  comparatively  wide  area  which  lies  between 
the  antero-lateral  and  postero-lateral  groups,  and  which  I  have 
already  named  the  medio-lateral  area  (Fig.  158,  ml) ;  it  is  filled 
with  small  ganglion  cells,  which  have  only  developed  processes 
towards  the  ninth  month  of  foetal  life. 

On  passing  now  to  the  upper  cervical  region  of  the  cord,  it 
will  be  observed  that  a  transposition  of  the  ganglion  groups 
takes  places  somewhat  similar  to  that  which  occurs  in  the  dorsal 
region.  Above  the  level  of  the  fifth  cervical  vertebra  the  area 
of  the  median  group  of  small  cells  rapidly  diminishes  in  size,  so 
that  the  antero-lateral  approximates  the  internal  group,  and 
the  small  anterior,  and  probably  also  the  central  groups  dis- 
appear. An  area  of  small  cells  is,  however,  interposed  between 
the  antero-lateral  and  postero-lateral  groups,  which  begins  to 


Fig.  157. 


Fig.  158. 


J'iGS.  157  and  158  (Young).  Stctions  of  the  Adult  Human  Spinal  Cord,  from  the 
upper  cervical  and  dorsal  regions  respectively. —A,  anterior,  and  P,  posterior 
horns  ;  aa,  anterior  roots ;  cc,  central  canal ;  ml,  the  medio-lateral  area.  The 
other  letters  indicate  the  same  as  the  corresponding  ones  in  Figs.  142  and  143. 
The  size  of  the  sections  from  which  the  drawing  was  taken  is  indicated  above 
each.     In  Fig.  168,  vc  represents  the  vesicular  column  of  Clarke. 


788        ANATOMICAL,  AND  PHYSIOLOGICAL  INTRODUCTION. 

show  itself  as  low  down  as  the  sixth  cervical  nerve,  and  gradually 
increases  in  size  to  the  upper  end  of  the  cord.  There  the  median 
group  disappears  entirely,  so  that  the  internal  and  antero-lateral 
groups  are  only  separated  by  a  small  vessel,  while  a  considerable 
area  of  small  cells  lies  between  the  antero-lateral  aod  postero- 
lateral groups  (Fig.  157,  ml).  The  distribution  of  the  different 
groups  in  the  upper  cervical  region  is,  indeed,  very  similar  to 
that  which  occurs  in  the  dorsal  region.  It  will,  however,  be 
seen,  on  comparing  Figs.  157  and  158,  that  the  central  group  is 
unrepresented  in  the  upper  cervical,  while  it  is  represented  in 
the  dorsal  region,  but  this  difference  is  unimportant,  since  I  am 
not  sure  that  the  group  is  always  absent  in  the  upper  cervical, 
or  always  present  in  the  dorsal  region.  One  important  difference, 
however,  exists  between  the  dorsal  and  upper  cervical  regions  of 
the  cord,  and  that  is  the  presence  of  the  vesicular  column  of 
Clarke  in  the  former  and  its  absence  in  the  latter.  The  vesi- 
cular column  of  Clarke  begins  at  the  upper  end  of  the  lumbar 
enlargement,  where  it  consists  of  a  group  of  large  bipolar  cells ; 
it  is  continued  upwards  throughout  the  whole  of  the  dorsal 
region,  although  its  cells  are  considerably  smaller  here  than  in 
the  upper  lumbar  region,  and  it  terminates  in  the  lower  part  of 
the  cervical  enlargement. 

(2)  Longitudinal  Distribution  of  the  Embryological  Systems 
of  the  White  Substance. 

§  358.  The  longitudinal  distribution  of  the  embryological 
systems  of  the  white  substance  must  now  be  described.  The  grey 
matter  extends  the  whole  length  of  the  cord,  and  its  size  main- 
tains a  constant  relation  to  the  number  and  variety  of  the 
movements  to  be  co-ordinated ;  hence  it  is  large  in  the  lumbar 
and  cervical  regions,  where  the  movements  of  the  limbs  are 
co-ordinated.  The  anterior  and  posterior  root-zones  also  extend 
the  whole  length  of  the  cord,  and,  speaking  broadly,  their  size 
maintains  a  pretty  constant  relation  to  the  size  of  the  grey 
matter,  although  there  is  probably  a  slight  increase  of  size  from 
below  upwards.  The  most  noticeable  feature  with  regard  to  the 
remaining  bundles  of  fibres  is,  that  they  increase  steadily  in  size 
from  below  upwards.     The  fibres  of  Goll  (Figs.  152  to  156,  G) 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.        789 

extend  the  -whole  length  of  the  cord,  but  they  gradually  diminish 
in  size  from  the  medulla,  so  that  mere  traces  of  them  are  to  be 
found  in  the  lumbar  region.  The  pyramidal  fibres  of  the  lateral 
columns  {Figs.  152  to  156,  pt)  also  extend  the  whole  length  of 
the  cord,  but  steadily  diminish  in  size  from  above  downwards^  so 
that  they  are  reduced  to  comparatively  small  bundles  in  the 
lumbar  region.  The  direct  cerebellar  fibres  of  the  lateral 
columns  {Figs.  153  to  156,  dc)  appear  in  the  cervical  region  as 
thin  lamellse  of  fibres,  one  on  each  side,  external  to  the  pyra- 
midal fibres.  They  diminish  in  size  from  above  downwards,  and 
disappear  somewhat  below  the  middle  of  the  dorsal  region,  so 
that  in  the  lower  dorsal  and  lumbar  regions  the  pyramidal  fibres 
come  to  the  surface  of  the  cord.  The  columns  of  Tiirck  or  the 
anterior  pyramidal  tracts  {Figs.  153  to  156,  T)  also  diminish  in 
size  from  above  downwards,  and  disappear  about  the  middle  of 
the  dorsal  region. 

The  relative  size  and  position  of  the  different  segments  of 
the  white  substance  may  be  seen  in  Figs.  152  to  156,  which 
represent  sections  of  the  spinal  cord  of  a  nine  months  human 
embryo  at  different  elevations.  The  fibres  of  the  pyramidal 
tracts  {pt)  of  the  lateral  columns,  and  of  the  columns  of  GoU 
(G)  and  of  Tiirck  (T),  have  assumed  a  medulla  at  the  ninth 
mpnth,  and  are  not,  therefore,  so  distinctly  marked  off  from  the 
remaining  portions  of  the  white  substance  as  they  are  repre- 
sented in  the  figures,  the  latter  being  in  this  respect  more  like 
the  appearances  presented  by  the  cord  between  the  fifth  and 
sixth  months  of  embryonic  life,  at  a  time  when  the  fibres  of  the 
anterior  and  posterior  root-zones  and  the  direct  cerebellar  tract 
are  alone  medullated. 

(D)  AxATOiTSr  OF  THE  MeDULLA  OBLONGATA,  PONS,  AND  CrURA  CEREBRI. 

The  consideration  of  the  internal  structure  of  the  medulla 
oblongata,  pons,  and  crura  cerebri  naturally  divides  itself  into  a 
description  of  (i.)  the  grey,  and  (il)  the  white  substance. 

(I.)   THE   GREY  SUBSTANCE. 

A  very  considerable  proportion  of  the  grey  substance  of  the 
medulla  oblongata,  pons,  and  crura  cerebri  is  merely  an  upward 


790        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

continuation  of  the  grey  substance  of  the  spinal  cord.  Portions 
of  this  grey  substance  become,  however,  specialised  in  the 
medulla  for  the  discharge  of  special  functions,  and  these  will 
require  separate  consideration.  In  addition  to  the  upward  con- 
tinuation of  the  grey  substance  of  the  spinal  cord,  the  cranial 
portion  of  the  spinal  axis  contains  masses  of  grey  matter  which 
do  not  belong  to  the  spinal  system,  and  these  will  be  described 
under  the  title  of  superadded  grey  matter.  Our  subject,  there- 
fore, may  be  considered  under  the  following  heads  : — (1)  a 
general  survey  of  the  grey  substance  of  the  medulla  oblongata, 
especially  at  its  junction  with  the  spinal  cord ;  (2)  the  upward 
continuation  of  the  anterior  grey  horns,  (3)  posterior  grey  horns, 
and  (4)  central  column  with  the  vesicular  column  of  Clarke  ;  (5) 
the  accessory  nuclei ;  (6)  the  special  nuclei  of  the  cranial  portion 
of  the  spinal  axis ;  and  (7)  the  superadded  grey  matter  of  the 
medulla  oblongata  and  pons. 

(1)  General  Remarks  on  the  Grey  Substance  of  the  Cranial 
'portion  of  the  Spinal  Axis. 

§  359.  In  the  upper  segment  of  the  spinal  cord  both  the  grey 
and  white  substances  undergo  extensive  rearrangement.  One 
important  alteration  of  the  white  substance  is  that  the  column 
of  Goll  increases  in  size  by  the  addition  of  grey  matter — the 
clavate  nucleus — in  its  interior  (Fig.  159,  G,  cu),  and  at  a  little 
higher  level  the  posterior  root-zone  also  increases  in  size  by  the 
formation  of  the  triangular  nucleus  in  its  substance  {Fig.  159, 
'pr,  tn).  The  increased  size  of  the  posterior  columns  displaces  the 
gelatinous  substance  of  the  posterior  grey  horns  {Fig.  159,  sg), 
so  that  they  extend  in  a  lateral  direction  instead  of  posteriorly 
as  in  the  cord.  Another  rearrangement  of  the  grey  substance  is 
produced  by  the  crossing  of  the  lateral  columns,  so  as  to  form 
the  anterior  pyramids  of  the  medulla  {Fig.  159,  x,  P).  These 
fibres  by  their  crossing  cut  off  the  anterior  grey  horns  from  the 
rest  of  the  grey  substance,  while  they  thrust  the  commissures, 
the  central  grey  column,  and  the  central  canal,  further  towards 
the  posterior  surface  of  the  medulla.  The  principal  alterations 
of  the  grey  substance,  therefore,  consist  in  the  lateral  displace- 
ment of  the  posterior  horns,  the  slight  posterior  displacement  of 


ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION.        791 

the  central  canal,  central  grey  column,  and  commissures,  and  the 
detachment  of  the  anterior  horns  from  the  central  grey  column, 
A  careful  examination,  however,  shows  that  one  or  two  other 
minor  but  exceedingly  important  alterations  have  taken  place. 


Fig.  159  ^ Young).    Section  of  the  Lower  End  of  the  Medulla  Oblongata  on  a  level  with 
the  crossing  of  the  fibres  of  the  lateral  column. 

A,  Anterior  grey  horns,  showing  that  the  grey  matter  has  become  mixed  np  with 
the  white  substance  of  the  anterior  root-zone,  and  with  arcuate  fibres. 
ixal,  Internal  group  and  a  portion  of  the  antero-lateral  group. 
aZc,  Anterior  nucleus  of  the  lateral  column,  being  a  portion  detached  from  the 

antero-lateral  group. 
pic,  Posterior  nucleus  of  the  lateral  column,  being  a  portion  detached  from  the 
postero-lateral  group. 
sg,  Substantia  gelatinosa  displaced  laterally. 
at,  Ascending  root  of  the  trigeminus. 
/,  Fasciculus  rotundus. 
vc,  "Vesicular  column  of  Clarke  ? 
P,  Pyramidal  tract. 

X,  Crossing  of  the  fibres, 

ar,  Internal  portion  of  the  anterior  root-zone. 
ai-'.  External  portion  of  the  anterior  root-zone. 
XII,  Hypoglossal  nerve. 

XI,  Spinal  accessory  nerve. 

G,  The  column  of  Goll — the  slender  fasciculus. 

en,  The  clavate  nucleus. 
pr.  The  posterior  root-zone — the  cuneate  fasciculus. 

tn,  The  triangular  nucleus.  cc,  The  central  canal. 


792        ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 


The  triangular  nucleus  and,  at  a  little  higher  level,  the  clavate 
nucleus  {Fig.  159,  tn,  en)  give  ofif  arcuate  fibres,  which  are 
directed  forwards  and  upwards  in  a  semicircular  manner  to  reach 
the  olivary  body  of  the  same  side.  These  fibres  pass  through 
the  posterior  horns  and  thrust  them  still  further  in  a  lateral 
direction,  and,  indeed,  almost  entirely  separate  the  greater 
portion  of  each  horn  with  its  substantia  gelatinosa  from  the 
grey  substance  which  surrounds  the  central  canal.  The  arcuate 
fibres  interlace  with  the  fibres  of  the  lateral  columns  as  the 
latter  bend  forwards  to  cross,  and  also  detach  a  portion  of  the 
antero-lateral  and  postero -lateral  groups  of  cells,  so  that  a  por- 
tion of  these  groups  now  extends  into  the  white  substance  of  the 
anterior  root-zones  {Fig.  159,  ale,  pic). 

The  continuation  of  the  anterior  root-zones  {Fig.  159,  ar  and 

Fig.  160. 


Fig.  160  (after  Henle).      Formatio  Reticularis  of  the  MeduUa  Oblongata,  showing 
the  Ganglion  Cells  distributed  through  it. 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.        793 

a.r)  of  the  cord  through  the  medulla  oblongata  is  broken  up 
into  a  reticulated  formation — the  formaiio  reticularis — first 
by  the  arcuate  fibres  of  the  triangular  and  clavate  nuclei,  and 
then  by  the  arcuate  fibres  of  the  inferior  peduncles  of  the  cere- 
bellum, and  the  whole  of  this  tissue  is  thickly  studded  with 
caudate  ganglion  cells,  as  represented  in  Fig.  160.  Whether  all 
these  cells  are  the  representatives  of  those  detached  by  the 
arcuate  fibres  from  the  antero-lateral  and  postero-lateral  groups 
of  the  cord  is  not  known.  The  cells  detached  from  these  groups, 
however,  aggregate  into  two  more  or  less  distinct  groups  in  the 
lateral  part  of  the  formatio  reticularis  of  the  medulla.  These 
groups  may  from  their  position  be  called  the  anterior  and  pos- 
terior nuclei  of  the  lateral  column  of  the  medulla  (Figs.  159, 
161,  and  162,  ale,  pic) ;  while  the  terms  antero-lateral  and 
postero-lateral  may  still  be  retained  to  designate  what  I  believe 
to  be  the  upward  continuations  of  the  portions  of  the  antero- 
lateral and  postero-lateral  (Fig.  135,  al,  pi)  groups  of  the  cord 
which  have  retained  their  connection  with  the  grey  matter  that 
may  be  considered  as  representing  the  anterior  cornua. 

(2)   Upward  Continuation  of  the  Anterior  Grey  Horns. 

§  360.  This  brief  description  of  the  rearrangement  of  the 
white  substance,  which  takes  place  in  passing  from  the 
spinal  cord  to  the  medulla  oblongata,  appeared  necessary  in 
order  fully  to  understand  the  redistribution  of  the  groups  of 
ganglion  cells  occurring  in  the  medulla.  At  the  lower  end  of 
the  medulla  portions  of  the  antero-lateral  and  postero-lateral 
groups  may  be  seen  to  extend  laterally  into  the  substance 
of  the  anterior  root-zone,  or  into  the  lateral  column  of  the 
medulla  oblongata  as  it  may  now  be  called.  From  the  anterior 
nucleus  of  the  lateral  column  {Fig.  159,  ale),  fibres  may  be 
observed  proceeding  inwards  and  passing  between  the  antero- 
lateral and  postero-lateral  groups.  Some  of  these  fibres  cross 
over  and  appear  to  be  connected  with  the  spinal  accessory  nerve 
of  the  opposite  side.  Others  wind  round  the  postero-lateral 
group  to  get  to  the  spinal  access(Jry  nerve  of  the  same  side. 
From  the  posterior  nucleus  of  the  lateral  column  {Fig.  159,  pic), 
fibres  proceed  inwards  to  reach  the  grey  substance,  and  wind 


794        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


Fig.  161. 


ip.       f 


Fig.  161  (Young).      Section  of  the  Medulla  Oblongata  on  a  level  with  the  Glosso- 
pharyngeal Nerve. 
P,  Pyramid. 

p,  Accessory  portion  of  the  pyramid. 
XII,  Hypoglossal  Nerve. 

H,  Nucleus  of  hypoglossal.    The  internal,  antero-lateral,  and  postero-lateral 
groups, 

a.  Anterior  group  of  cells, 
IX,  Glosso-pharyngeal  nerve. 

ngp.  Nucleus  of  glosso-pharyngeal. 

VIII,  Lower  part  of  the  posterior  median  acoustic  nucleus. 

if.  Internal  accessory  facial  nuclei. 

ef.  External  accessory  facial  nuclei. 

ale,  Anterior  nucleus  of  the  lateral  column. 

pic,  Posterior  nucleus  of  the  laferal  column. 
/,  Fasciculus  rotundus. 

ip,  Internal  division  of  the  inferior  peduncle  of  the  Cdrebellum. 
G,  Column  of  Goll. 

en,  Clavate  nucleus. 


ANATOMICAL  AND  PHTSIOLOGICAL  INTRODUCTION.        795 

backwards  along  the  boundary  line  between  the  white  and  grey 
substance  to  reach  the  spinal  accessory  nerve  of  the  same  side. 
The  nuclei  of  the  lateral  column,  therefore,  appear  to  give  origin 
to  some  at  least  of  the  j&bres  of  the  spinal  accessory  nerve ;  and 
we  have  only  to  suppose  that  the  same  arrangement  is  carried 
out  as  we  ascend  the  medulla  and  pons  in  order  to  understand 
the  origin  of  the  motor  fibres  of  the  pneumogastric  and  glosso- 
pharyngeal nerves,  those  of  a  large  part  of  the  facial  nerve,  and 
of  the  motor  root  of  the  fifth.  The  arrangement  of  the  fibres 
from  the  nuclei  of  the  lateral  column  which  pass  out  along  with 
the  glosso-pharyngeal  nerve  is  represented  in  Fig.  161.  The 
fibres  from  the  anterior  nucleus  {Fig.  161,  ale)  proceed  back- 
wards and  inwards,  and  pass  between  what  will  be  afterwards 
described  as  the  antero-lateral  and  postero-lateral  groups.  I 
have  not  been  able  to  assure  myself  that  any  of  these  fibres 
cross  over  to  the  opposite  side,  although  this  is  probable}  but 
some  of  them  may  be  distinctly  observed  to  wind  round  the 
postero-lateral  nucleus  to  proceed  in  the  direction  of  the  glosso- 
pharyngeal nerve.  The  fibres  from  the  posterior  nucleus  {Fig. 
161,  'plc)  proceed  backwards  and  inwards,  and  on  reaching  the 
grey  substance  bend  abruptly  outwards  along  the  edge  of  the 
white  substance  to  reach  the  nerve.  A  similar  arrangement 
may  be  observed,  at  a  lower  level,  with  respect  to  the  pneumo- 
gastric and  spinal  accessory  nerves.  At  a  higher  elevation  the 
fibres  from  the  nuclei  of  the  lateral  column  proceed  backwards 
and  inwards,  the  majority  of  them  (genu  nervi  facialis)  wind 
round  the  nucleus  of  the  sixth  nerve,  and  proceed  outwards  to 
join  the  facial  nerve.  The  fibres  from  the  posterior  nucleus  of 
the  lateral  column  {Fig.  163,  ylc)  appear  to  me  to  pass  back- 


er, Posterior  root-zone. 

tn,  Triang\ilar  nucleus. 
dc.  The  direct  cerebellar  tract  Ijdng  on  the  surface  of  the  posterior  root-zone,  and 

the  ascending  root  of  the  trigeminus, 
at,  Ascending  root  of  the  trigeminus. 

sg.  Substantia  gelatinosa. 
L,  Posterior  longitudinal  fasciculus. 
ar.  The  portion  of  the  formatio  reticularis,  which  represents  the  internal  division  of 

the  anterior  root-zone  of  the  spinal  cord. 
ar',  The  portion  of  the  formatio  reticularis,  which  represents  the  external  division  of 

the  anterior  root-zone  of  the  spinal  cord. 
0,  Olivary  body. 

np.  Nucleus  of  the  pyramid. 
po,  Parolivary  body. 


796        ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 

wards  and  to  the  outside  of  the  nucleus  of  the  sixth  nerve  to 
join  the  facial.  The  anterior  nucleus  of  the  lateral  column 
appears  to  terminate  on  a  level  with  the  origin  of  the  facial 
nerve.  Fibres,  however,  seem  to  pass  upwards  and  backwards 
from  this  nucleus  to  join  the  motor  root  of  the  fifth  nerve.  In 
Fig.  164  the   anterior  nucleus  of  the  lateral   column  of  the 

Fig.  162. 


Fig.  162  (modified  from  Flechsis?).     Section  of  the  Medulla  Oblongata  on  a  level  with 
the  superficial  origin  of  the  Acoustic  Nerve. 

K  VIII,  Root  of  the  acoustic  nerve. 

VIII,  Posterior  median  acoustic  nucleus. 

viil",  Posterior  lateral  acoustic  nucleus. 

H,  Nucleus  of  the  hypoglossal  nerve. 
ip,  Internal  division  of  the  inferior  peduncle  of  the  cerebellum. 
ep,  External  division  of  the  inferior  peduncle  of  the  cerebellum. 
frs,  Formatio-reticularis. 

a,  Arciform  fibres.     The  remaining  letters  indicate  the  same  as  the  corre- 
sponding letters  in  Fig.  161. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 


797 


medulla  is  not  represented,  but  the  fibres  transversely  cut  at  (r) 
shows  that  these  have  joined  the  others  from  a  different  level, 
and  I  believe  that  these  fibres  have  ascended  from  the  anterior 
nucleus  of  the  lateral  column.  The  motor  nucleus  of  the  fifth 
{Fig.  164,  v)  appears  to  be  the  continuation  upwards  of  the  pos- 
terior nucleus  of  the  lateral  colmmn.  The  nucleus  now  lies  close 
to  the  sensory  fibres  of  the  nerve,  and  its  fibres,  instead  of 
winding  backwards  at  first,  as  they  do  at  a  lower  level,  appear  to 
pass  outwards  at  once  by  the  side  of  the  sensory  fibres. 

The  groups  of  cells  of  the  anterior  horns  may  be  traced 
upwards  more  or  less  distinctly  to  the  nucleus  of  origin  of 
the  hypoglossal  nerve.  The  hypoglossal  nucleus  begins  on  a 
level  with  the  upper  limit  of  the  crossing  of  the  fibres  of  the 


Rvn 


Fig.  163  (modified  from  Erb).  Transverse  Section  of  the  Pons  on  a  level  with  the 
Abducens  and  Facial  Roots,  from  a  nine-months  embryo. — The  right  half  repre- 
sents a  section  made  a  little  lower  than  the  left.  P,  Pyramidal  tract;  p, 
accessory  portion  of  tlie  pyramidal  tract ;  Tr  and  T?*',  transverse  fibres  of  the 
pons  ;  so,  superior  olivary  body  ;  ale  and  'plc,  anterior  and  posterior  nuclei  of  the 
lateral  column  respectively,  representing  the  nucleus  of  the  facial  nerve  ;  evii, 
root  of  the  facial  nerve  ;  vi',  nucleus  of  the  sixth  nerve  ;  EVi,  root  of  the  sixth 
nerve ;  at,  ascending  root  of  the  trigeminus.  B,  The  internal  division  of  the 
peduncle  of  the  cerebellum  as  it  passt s  from  the  cerebellum  ;  L,  posterior  longi- 
tudinal fasciculus  ;  ar  and  ar',  the  upward  continuation  of  the  internal  and 
external  divisions  of  the  anterior  root-zone  of  the  spinal  cord  ;  t,  fasciculus  teres. 


798        ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION. 

pyramidal  tract.  The  crossing  of  the  fibres  had  detached  the 
anterior  horns  from  the  grey  substance  surrounding  the  central 
canal;  but  when  the  crossing  is  completed,  these  two  portions 
again  become  united.  The  olivary  body  is,  however,  inter- 
calated, and  the  whole  of  the  grey  matter  is  thrust  further  and 
further  back  until  the  posterior  commissure  disappears,  and  the 
central  canal  opens  at  the  calamus  scriptorius  on  the  floor  of  the 
fourth  ventricle.  The  nucleus  of  the  hypoglossal  nerve  is  often 
described  as  if  its  cells  constituted  one  group.  These  cells  are, 
however,  distinctly  arranged  into  several  groups  which  corre- 
spond so  closely  with  the  arrangement  of  the  groups  in  the 
anterior  horns  of  the  cord  that  I  have  no  hesitation  in  regard- 


FlO.  164  (modified  from  Erb).  Transverse  Section  of  the  Pons  on  a  level  with  the 
oHgin  of  the  Trigeminus,  from  a  nine-months  human  embryo.— P,  pyramidal  tract ; 
p,  accessory  portion  of  the  pyramidal  tract ;  Tr,  Tr',  transverse  fibres  of  the 
pons;  at,  ascending  root  of  the  trigeminus  and  gelatinous  substance;  dt, 
descending  root  of  the  trigeminus;  r,  root-fibres  of  the  trigeminus  cut  trans- 
Tersely;  V,  motor  nucleus  of  the  trigeminus;  v',  middle  sensory  trigeminal 
nucleus ;  RV,  root  of  trigeminus ;  G,  roots  of  the  fifth  proceeding  from  the  cere- 
bellum ;  L,  posterior  longitudinal  fasciculus  ;  ar  and  ar\  upward  continuation 
of  the  internal  and  external  portions  respectively  of  the  anterior  root-zone  of  the 
spinal  cord. 


ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 


799 


ing  those  of  the  former  as  continuations  of  the  latter.  An 
interna],  antero-lateral,  and  postero -lateral  {Fig.  135,  i,  al,  pi) 
group  may  be  distinguished,  and  these  appear  to  correspond  to 
the  groups  of  the  same  name  in  the  cord ;  while  a  large  number 
of  cells  may  be  observed  at  the  roots  of  the  hypoglossal  nerve 
(Fig.  135,  a),  which  may  be  called  the  anterior  group,  and  which 
corresponds  to  the  anterior  group  in  the  cord.  All  that  has  been 
previously  said  with  regard  to  the  development  of  the  groups  of 
cells  in  the  anterior  horns  of  the  cord  applies  equally  to  those  of 
the  hypoglossal  nucleus.  The  central  cells  of  the  latter  groups 
develop  first,  while  the  marginal  cells  develop  last  and  close  to 
the  blood-vessels  which  ramify  between  the  groups  as  they  do  in 
the  cord. 

Fig.  165. 


Fl&.  165  (modified  from  Meynert^  Transverse  Section  of  the  Pons  on  a  level  mith  the 
upper  end  of  the  Fourth  Ventricle,  from  a  nine-months  human  embryo. — P,  pyra- 
midal tract ;  p,  accessory  portion  of  the  pyramidal  tract ;  Tr,  Tr',  transverse 
fibres  of  the  pons ;  B,  superior  brachium  of  the  pons  ;  L,  posterior  longitudinal 
fasciculus ;  ar  and  ar',  upward  continuation  of  the  internal  and  external  portions 
respectively  of  the  anterior  root-zone  of  the  spinal  cord ;  v',  middle  sensory 
trigeminal  nucleus  ;  dt,  descending  root  of  the  trigeminus  ;  iv,  nucleus  of  the 
fourth  nerve  ;   cc,  aqueduct  of  Sylvius. 


800 


ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 


It  is  not  easy  to  trace  the  continuation  of  the  groups  of  cells 
of  the  anterior  horns  of  the  cord  beyond  the  nucleus  of  the 
hypoglossal  nerve,  inasmuch  as  the  groups  become  separated 
longitudinally  by  the  transverse  fibres  of  the  pons.  It  is,  how- 
ever, probable  that  the  nucleus  of  the  sixth  nerve  {Fig.  163,  Vl') 
represents  the  postero-lateral  group,  and  the  bending  of  the 
fibres  of  the  facial  nerve  round  the  nucleus  corresponds  to  the 
similar  bending  of  the  fibres  which  issue  from  the  anterior 
nucleus  of  the  lateral  column  in  the  lower  part  of  the  medulla 

Tig.  166. 


!ElG.  166  (modified  from  Krause).  Transverse  Section  of  the  Cms  Cerebri  on  a  level 
'  with  the  anterior  ^yair  of  Corpora  Quadrigemina,  from  a  nine-months  embryo. — 
cc,  crusta ;  P,  pyramidal  tract ;  p,  accessory  portion  of  the  pyramidal  tract ; 
LN,  locus  niger  ;  RN,  red  nucleus  of  the  tegmentum  ;  L,  posterior  longitudinal 
fasciculus ;  ar  and  ar',  upward  continuation  of  the  internal  and  external  portions 
respectively  of  the  anterior  root-zone  of  the  spinal  cord ;  iii,  third  nerve ; 
III',  nucleus  of  the  third  nerve ;  IV,  fourth  nerve ;  iv',  nucleus  of  the  fourth 
nerve ;  iv",  crossing  of  the  fibres  of  the  fourth  nerve  to  opposite  sides ;  dt, 
descending  root  of  the  trigeminus ;  cc,  aqueduct  of  Sylvius ;  x,  crossing  of  the 
fibres  of  the  superior  peduncles  of  the  cerebellum  ;  pf,  fasciculus  of  meduUated 
fibres  proceeding  from  the  fillet  to  the  anterior  pair  of  corpora  quadrigemina. 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.         801 

round  the  postero-lateral  group  to  join  the  spinal  accessory 
nerve.  The  postero-lateral  group  cannot  be  traced  beyond  the 
nucleus  of  the  sixth  nerve,  and  probably  ceases  there.  The 
internal,  anterior,  and  antero-lateral  groups  are  dislocated  up- 
wards, as  a  result  probably  of  the  longitudinal  extension  of  the 
central  grey  tube,  which  is  rendered  necessary  in  order  to  pro- 
vide accommodation  for  the  large  mass  of  the  transverse  fibres  of 
the  pons.  These  groups  reappear  in  front  of  the  aqueduct  of 
Sylvius,  and  form  the  nuclei  of  the  third  and  fourth  nerves 
(Fig.  166,  III',  IV').  The  fourth  nerve  is  in  my  opinion  merely 
a  portion  detached  from  the  third  by  the  decussating  fibres  of 
the  superior  peduncles  of  the  cerebellum,  and  thus  compelled  to 
seek  its  destination  by  an  independent  route.  The  fourth  nerve, 
therefore,  appears  to  belong  to  the  system  of  anterior  motor 
nerves  represented  by  the  hypoglossal,  sixth,  and  third  nerves, 
and  not  to  the  "  mixed  lateral  system  "  represented  by  the  spinal 
accessory,  vagus,  glosso-pharyngeal,  and  fifth  nerves.  Although 
the  facial  is  a  purely  motor  nerve,  it  appears  to  belong  at  least 
in  part  to  that  lateral  system.  That  the  nucleus  of  the  sixth  on 
the  one  hand  and  that  of  the  third  and  fourth  on  the  other 
really  belong  to  the  same  nucleus,  and  are  only  separated  from 
one  another  by  some  structure  being  intercalated  in  the  course 
of  evolution,  is  rendered  probable  by  the  fact  that  the  nucleus  of 
the  sixth  is  connected  by  a  distinct  bundle  of  fibres  with  the 
third  nerve  of  the  opposite  side,  or  with  its  nucleus.^  The  fact 
that  these  nerves  are  so  closely  related  in  their  functions  affords 
further  corroborative  evidence  in  favour  of  this  opinion. 

(3)   Upward  Continuation  of  the  Posterior  Grey  Horvs. 

§  361.  We  have  already  seen  that  the  substantia  gelatinosa 
of  the  posterior  horns  was  not  only  thrust  out  laterally,  but  also 
almost  detached  from  the  rest  of  the  grey  substance  by  the 
arcuate  fibres,  and  we  must  now  observe  that  it  maintains  this 
lateral  and  superficial  position  as  high  as  the  level  of  the  point 
of  emergence  of  the  fifth  nerve  (Figs.  159  to  163,  at).  It 
may,  indeed,  be  said  that  this  structure  is  continued  upwards 
to  the  level  of  the  opening  of  the  aqueduct  of  Sylvius  into  the 

'  Duval  (M.).    "  Origine  des  nerfs  cr^niens."   Journal  de  I'anat.  et  de  la  physiol. 
Juilliet,  1879,  et  Janvier,  1880. 

VOL.  I.  ZZ 


802        ANATOMICAL   AND  PHYSIOLOGICAL  INTBODUCTION. 

third  ventricle,  since  the  descending  root  of  the  fifth  nerve 
appears  to  be  a  somewhat  similar  structure  to  the  ascending 
root  and  gelatinous  substance  {Figs.  164  to  166,  dt). 


(4)    Upward  Continuation  of  the  Central  Column  and  the 
Vesicular  Column  of  Clarke, 

§  362.  In  the  dorsal  region  of  the  spinal  cord  the  middle  portion 
of  the  grey  substance  is  represented  by  two  columns  on  each  side 
of  the  central  canal — the  vesicular  column  of  Clarke,  and  the 
central  column — but  the  column  of  Clarke  is  unrepresented  in 
the  lumbar  and  cervical  regions  of  the  cord.     It  appears  to  me. 

Fig.  167. 


Fio.  167  (Young).    Section  of  the  Medulla  Oblongata,  a  little  beloiv  the  point  of  the 

Calamus  Scriptorius,  showing  the  groups  of  cells  of  the  grey  substance. 
Kxi,  Fibres  of  origin  of  the  eleventh  or  spinal  accessory  nerve. 

XI,  Posterior  nucleus  of  the  eleventh  nerve. 

xi',  Accessory  nucleus  of  the  eleventh  nerve. 
Rxii,  Fibres  of  origin  of  the  twelfth  or  hypoglossal  nerve. 

a,  i,  al,  pi,  Anterior,  internal,  antero-lateral,  and  postero-lateral  groups  of 
cells  respectively. 

ah,  Accessory  hypoglossal  nucleus. 

if.  Internal  accessory  facial  nuclei. 

ef,  External  accessory  facial  nucleus. 
C,  Central  canal. 
/,  Fasciculus  rotundus. 


ANATOMICAL  AXD  PHYSIOLOGICAL   INTRODUCTION.        803 

however,  that  the  vesicular  column  of  Clarke  again  becomes  repre- 
sented in  the  lower  end  of  the  medulla.  A  group  of  cells  may  be 
observed  near  the  posterior  and  internal  margin  of  the  central 
column  in  the  lower  end  of  the  medulla  {Fig.  159,  vc),  corre- 
sponding to  the  position  occupied  by  the  vesicular  column  of 
Clarke  in  the  dorsal  region  ;  and  the  cells  of  both  groups  mani- 
fest a  tendency  to  be  bipolar,  instead  of  multipolar  like  those  of 
the  anterior  horns.  Assuming,  therefore,  that  the  group  of  cells 
in  the  middle  portion  of  the  grey  matter  in  the  lower  end  of  the 
medulla  is  the  upward  continuation  of  the  vesicular  column  of 
Clarke,  and  that  the  remaining  portion  represents  the  central 
column  in  the  cord,  we  shall  have  no  difficulty  in  tracing  the 
disposition  of  these  portions  of  grey  substance  in  the  medulla. 
Immediately  above  the  crossing  of  the  pyramidal  fibres,  where 
the  anterior  horns  are  pressed  backwards  towards  the  central 
canal,  the  central  column  lies  posterior  to  the  groups  of  cells 
representing  the  anterior  horns,  and  close  to  the  central  canal, 
while  the  representative  of  the  vesicular  column  of  Clarke  lies 
external  to  the  central  column,  and  posterior  to  the  groups 
representing  the  anterior  grey  horns  {Fig.  167,  xi).  The 
nucleus  which  represents  the  vesicular  column  of  Clarke  con- 
tains pigmented  bipolar  cells,  and  constitutes  the  posterior 
nucleus  of  the  spinal  accessory  nerve  {Fig.  167,  xl).  And 
when  the  central  canal  has  opened  into  the  floor  of  the  fourth 
ventricle,  the  representative  of  the  vesicular  column  of  Clarke 
is  thrust  backwards,  and  laterally  so  as  to  form  the  principal 
part  of  the  nuclei  of  origin  of  the  spinal  accessory,  vagus,  and 
glosso-pharyngeal  nerves,  while  the  central  column  winds  round 
the  groups  representing  the  anterior  horns  {Fig.  161,  H),  so  as 
to  lie  internal,  posterior,  and  external  to  them.  The  posterior 
portion  of  the  central  column  is  elevated  into  a  ridge  (funiculus 
teres)  close  to  the  median  fissure  in  the  inferior  part  of  the  floor 
of  the  fourth  ventricle  {Fig.  102,  if).  The  central  column  is 
continued  upwards,  as  a  thin  film  of  grey  substance,  on  the  floor 
of  the  fourth  ventricle,  which  lies  behind  the  fibres  of  origin  of 
the  facial  {Fig.  163,  t)  and  the  fifth  nerves  {Fig.  164,  r),  and  in 
the  upper  end  of  the  pons  and  crura  it  is  represented  by  the 
grey  matter  which  immediately  surrounds  the  aqueduct  of 
Sylvius  {Figs.  165  and  166,  cc). 


804        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

The  characteristics  of  the  central  column  are,  as  we  have 
already  seen,  that  its  texture  is  spongy,  rendering  it  transparent 
on  section,  and  that  its  cells  are  comparatively  late  in  their 
development.  We  saw  reason,  indeed,  to  regard  the  central 
column  as  being  the  embryonic  part  of  the  central  grey  tube, 
and  that  the  portions  of  it  which  are  first  developed  are  thrust 
outwards  as  new  layers  grow  about  the  central  canal.  If  this  be 
true,  we  may  expect  to  find  that  any  additional  nuclei  which 
may  form  in  the  medulla  oblongata  in  the  course  of  development 
will  grow  in  the  representative  of  the  central  column.  This 
expectation  is  realised.  Whether  the  spoDgy  portion  of  grey 
substance,  which  lies  internal,  posterior,  and  external  to  the 
hypoglossal  nucleus,  be  or  be  not  the  continuation  upwards 
of  the  central  column,  several  groups  of  cells  may  be  observed 
in  it  which  do  not  become  developed  until  subsequently  to  the 
ninth  month  of  embryonic  life,  and  which  do  not  appear  to  be 
represented  in  the  spinal  cord ;  they  may,  therefore,  be  called 
the  accessory  nuclei  of  the  medulla  oblongata.  These  nuclei 
must  be  carefully  distinguished  from  the  nuclei  of  origin  of  the 
spinal  accessory  nerve. 

(5)  Accessory  Nuclei  of  the  Medulla  Oblongata. 

§  863.  (a)  Accessory  N'uclei  of  the  Facial  Nerve. — The  first  of 
these  which  I  shall  mention  is  what  has  been  described  by  Dr. 
Lockhart  Clarke  as  the  inferior  facial  nucleus.  This  nucleus 
consists  really  of  several  small  nuclei.  Two  of  these,  which  may 
be  called  the  internal  accessory  facial  nuclei  {Fig.  161,  if),  appear 
as  two  small  round  nuclei  close  to  the  inner  side  of  the  hypo- 
glossal nucleus  and  the  central  canal ;  and  when  the  canal  opens 
on  to  the  floor  of  the  fourth  ventricle,  they  are  situated  imme- 
diately beneath  the  ependyma  of  the  ventricle,  and  close  to  the 
middle  line  (Fig.  162,  if).  Fibres  from  these  nuclei  ascend  in 
the  funiculus  teres  and  enter  the  fasciculus  teres  (Fig.  163,  t), 
through  which  they  join  the  other  fibres  of  the  facial  nerve. 

Another  somewhat  larger  group  of  small  cells  is  situated  at 
first  posterior  (Fig.  161,  ef)  and  then  external  (Fig.  162,  ef)  to 
the  nucleus  of  the  hypoglossal.  The  fibres  which  issue  from  it 
also  join,  I  believe,  the  fasciculus  teres,  and  the  group  may, 
therefore,  be  called  the  external  accessory  facial  nucleus  (Fig. 


ANATOMICAL  AND   PHYSIOLOGICAL  INTRODUCTION.        805 

162,  ef).  The  cells  of  these  nuclei  are  small,  and  destitute  of 
processes  in  a  nine-months  embryo. 

(6)  Accessory  Nuclei  of  the  Eleventh  Nerve. — Two  groups  of 
small  cells,  which  develop  at  a  comparatively  late  period,  may 
be  observed  lying  behind  the  posterior  nucleus  of  the  eleventh 
nerve  [Fig.  166,  xi').  Meynert  thinks  that  the  cells  of  these 
groups  are  connected  with  commissural  fibres  which  run  behind 
the  central  canal,  before  it  opens  into  the  fourth  ventricle. 

(cj  Accessory  Nucleus  of  the  Hypoglossal  Nerve. — The  next 
most  important  nucleus  of  this  category  is  one  which  I  have 
constantly  observed  in  the  hypoglossal  nucleus  of  one  side  only 
{Fig.  167,  oh).  As  I  have  not  marked  my  sections,  I  am  at 
present  unable  to  say  whether  it  is  found  on  the  right  or  left 
side.  This  nucleus  is  of  a  round  form,  and  appears  as  if  it  were 
surrounded  by  a  layer  of  white  fibres,  arranged  longitudinally, 
which  separates  it  from  the  surrounding  tissue.  It  contains  a 
large  number  of  very  small  caudate  cells,  each  being  not  one-fifth 
the  diameter  of  the  cells  of  the  hypoglossal  nucleus.  The 
nucleus  in  some  sections  lies  between  the  internal  and  external 
convolute  of  the  nucleus  of  the  hypoglossal;  while  at  other 
times  it  is  embedded  in  the  substance  of  the  internal  convolute, 
being  then  situated  near  the  margin  of  the  group  {Fig.  167). 
This  nucleus  is  almost  entirely  limited  to  one  side,  although 
faint  traces  of  it  may  occasionally  be  observed  in  the  opposite 
side ;  it  is  scarcely  recognisable  on  either  side  of  the  medulla  at 
the  ninth  month  of  embryonic  life.  The  most  reasonable  sup- 
position with  regard  to  it  is  that  it  regulates  the  movements  of 
articulation,  and  that  it  is  connected  with  the  third  left  frontal 
convolution  of  the  brain. 

(6)  Special  Nuclei  of  the  Medulla  Oblongata  and  Pons. 

§  364.  {a)  The  acoustic  nuclei  can  scarcely  be  said  to  be  repre- 
sented by  any  portion  of  the  grey  substance  of  the  cord.     These 
nuclei  are  four  in  number  : — 

( i. )  The  posterior  median  nucleus  of  the  acousticus 
{Fig.  162,  VIII )  comes  in  contact  with  the  nucleus  of  the 
vagus,  but  is  more  superficially  situated  than  that  of  the  latter, 
an^  somewhat  to  the  outer  side  of  the  glosso-pharyngeal  nucleus. 


806        ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 

It  occupies  the  whole  space  between  the  ala  cinerea  and  inferior 
peduncle  of  the  cerebellum  up  to  the  anterior  border  of  the  striae 
medullares.  The  posterior  root  of  the  acoustic  nerve  takes  its 
origin  chiefly  from  this  nucleus,  and  passes  out  partly  in  super- 
ficial fasciculi  (striae  acousticse)  and  partly  through  the  body  of 
the  medulla. 

(ii.)  The  'posterior  lateral  acoustic  nucleus  {Fig.  125,  viii")  is 
a  grey  nodule  lying  in  the  peduncle  of  the  cerebellum,  between 
the  deep  and  superficial  fibres  of  origin  of  the  acoustic  nerve. 

(iii.)  The  anterior  median  acoustic  nucleus  belongs  to  the 
anterior  roots  of  the  acoustic  nerve,  and  is  situated  anterior 
to  the  striae  medullares.  It  occupies  the  external  angle  of  the 
fourth  ventricle,  about  the  middle  of  the  cerebellar  peduncle. 

(iv.)  The  anterior  lateral  acoustic  nucleus  appears  like  a  pro- 
longation of  the  posterior  lateral  acoustic  nucleus,  and  is  wedged 
in  between  the  middle  peduncle  and  the  flocculus.  It  gives 
orio-in  to  the  portio  intermedia  Wrisbergii.  Some  anatomists 
believe  that  the  fibres  which  pass  in  the  chorda  tympani,  and 
which  confer  taste  on  the  anterior  two-thirds  of  the  tongue,  are 
derived  from  the  nerve  of  Wrisberg  (Bigelow).  It  is  also 
probable  that  one  of  the  other  nuclei — perhaps  the  posterior 
lateral  acoustic  nucleus — gives  origin  to  the  fibres  supplied  to 
the  labyrinth,  and  is  not  connected  with  the  purely  acoustic 
fibres. 

(6)  The  corpora  quadrigemina  and  the  internal  geniculate 
tody  are  the  nuclei  of  origin  of  the  second  or  optic  nerve,  but 
we  are  unable  to  say,  in  the  present  state  of  our  knowledge,  what 
structures  constitute  the  nuclei  of  origin  of  the  first  or  olfactory 
nerve. 

(7)  Superadded  Grey  Matter  of  the  Medulla  Oblongata  and 

Pons. 

§  365.  (a)  The  Clavate  Nucleus. — The  columns  of  Goll  con- 
tain in  the  lower  part  of  the  medulla  a  nucleus  of  grey  matter, 
which  is  from  its  form  called  the  clavate  nucleus  {Figs.  159  and 
161,  en).  It  is  a  longitudinal  pillar  of  grey  substance,  and 
produces  the  enlargement  in  the  fasciculus  gracilis,  known  as 
the  clava. 

(6)  The  triangular  nucleus  {Figs.  159  and  161,  tn)  is  a  grey 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.        807 

nucleus  enclosed  in  the  cuneate  fasciculus,  the  latter  of  which  is 
the  continuation  upwards  of  the  posterior  root-zones  of  the  cord. 
It  is  a  longish  grey  body  on  the  inner  border  of  the  cuneiform 
column,  and. enlarging  as  it  ascends.  The  clavate  and  triangular 
nuclei  extend  to  the  posterior  end  of  the  postero-lateral  acoustic 
nucleus. 

(c)  The  olivary  body  (Fig.  161,  o)  is  situated  in  the  lateral 
columns  of  the  medulla,  close  to  the  anterior  pyramid.  In  form 
it  is  like  a  bean  or  an  almond,  with  the  hilus  directed  inwards. 
It  contains  a  number  of  small  ganglion  cells,  and  is  in  substance 
very  similar  to  the  corpus  dentatum  of  the  cerebellum. 

{d)  The  parolivary  body  {Fig.  161,  po)  is  a  band  of  grey 
matter  which  bounds  the  internal  half  of  the  posterior  border 
of  the  olivary  body. 

(e)  The  nucleus  of  the  pyramid  {Fig.  161,  np)  (internal 
parolivary  body)  lies  opposite  the  pyramid,  in  front  and  to  the 
inside  of  the  olivary  body. 

(/)  The  superior  olivary  body  {Fig.  163,  so)  is  a  longish,  grey 
column,  situated  in  the  pons  in  front  of  the  facial  nucleus. 

(g)  The  red  nucleus  of  the  tegmenturri  (Fig.  166,  RN")  of 
Stilling,  or  superior  olive  of  Luys,  is  situated  in  the  crus  cerebri, 
between  the  crus  and  tegmentum,  and  is  similar  in  structure  to 
the  olivary  body. 

{h)  The  middle  sensory  nucleus  of  the  trigeminus  {Figs.  164 
and  165,  v')  is  also  a  superadded  structure.  This  nucleus  is 
situated  in  the  substance  of  the  afferent  fibres  of  the  trigeminus, 
not  far  from  their  entrance  into  the  pons.  In  structure  it  is 
somewhat  similar  to  that  of  the  ganglia  of  the  posterior  roots, 
and  it  may  represent  the  ganglion  of  the  descending  roots,  while 
the  Gasserian  ganglion  represents  that  of  the  ascending  roots  of 
the  nerve. 

{i)  The  external  geniculate  body  contains  numerous  large- 
branched  ganglion  cells  formed  into  layers,  between  which  the 
fibres  of  the  outer  portion  of  the  optic  tract  pass.  The  ganglion 
cells  of  this  body  are  like  those  of  the  ganglia  of  the  posterior 
spinal  roots,  and  it  is  therefore  probable  that  the  external 
geniculate  body  stands  in  the  same  relation  to  the  optic  nerve 
tkat  the  ganglia  of  the  posterior  roots  do  to  the  spinal  nerves. 


808        ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION. 

(II.)    THE    WHITE    SUBSTAXCE. 

The  internal  arrangement  of  the  white  substance  of  the 
medulla  oblongata  and  pons  will  be  best  understood  if  we 
describe,  (1)  the  upward  continuation  of  embryological  systems 
of  the  white  substance  of  the  cord  into  or  through  the  medulla 
and  pons ;  and  (2)  the  superadded  white  substance  which  does 
not  belong  to  the  spinal  system. 

(1)   Upward  Continuation  of  the  Embryological  Systenns  of  the 

Spinal  Cord. 

§  366.  It  will  be  most  convenient  to  describe  first  the  systems 
which  pass  upwards  through  the  whole  length  of  the  medulla 
oblongata  and  pons,  and  leave  to  the  last  the  description  of  those 
which  terminate  in  them.  The  position  of  the  sensory  conduct- 
ing paths  can  hardly  be  said  to  have  been  revealed  by  anatomy, 
either  in  the  spinal  cord  or  the  medulla  oblongata  and  pon.s,  but 
it  will  nevertheless  be  found  useful  if  we  avail  ourselves  of  the 
knowledge  obtained  from  physiological  experiment  and  patho- 
logical observation,  in  order  to  trace  in  this  place  the  course  of 
those  paths  throughout  the  whole  length  of  the  spinal  axis. 
Our  subject  then  may  be  divided  into  a  description  of  the 
upward  continuation  of  (a)  the  pyramidal  tract,  giving  (&)  a 
separate  description  of  the  accessory  portions  of  these  tracts  ;  (c) 
the  anterior  root-zones ;  {d)  the  direct  cerebellar  tracts,  and  (e) 
the  posterior  root-zones  and  the  columns  of  GoU.  In  addition, 
we  shall  describe  (/)  the  course  of  the  sensory  conducting  paths 
throughout  the  length  of  the  spinal  axis. 

(a)  The  Pyramidal  Tract. 

The  pyramidal  fibres  of  the  lateral  columns  at  the  upper  end 
of  the  cervical  region  of  the  cord  pass  forwards  and  inwards 
towards  the  anterior  median  fissure.  These  fibres  decussate  with 
one  another  in  the  medulla,  so  that  those  of  the  right  side  pass 
to  the  left,  and  those  of  the  left  to  the  right.  The  decussation 
frequently  begins  in  the  upper  portion  of  the  cord ;  while  the 
homologues  of  the  pyramidal  fibres,  which  arise  from  the  nerve- 
nuclei  of  the  hypoglossal  and  facial  nerves,  cross  separately  in  the 
pons  above  the  decussation  of  the  pyramids.      The  pyramidal 


ANATOMICAL   AND   PHYSIOLOGICAL   INTEODUCTION.        809 

fibres  of  the  lateral  columns  during  and  subsequent  to  their 
decussation  come  forwards  into  the  anterior  median  fissure, 
and  push  aside  the  columns  of  Tiirck  {Fig.  156,  T),  so  that 
the  latter  form  a  prismatic  bundle  of  fibres  external  to 
the  former,  and  ascend  without  decussating  with  one  another. 
These  two  sets  of  fibres  constitute  the  anterior  pyramids  of 
the  medulla  {Figs.  159  to  162,  P) ;  they  can  be  traced 
through  the  pons  {Figs.  163  to  165,  P),  where  they  receive 
a  large  accession  to  their  size,  into  the  peduncles  of  the  cere- 
brum. According  to  the  researches  of  Flechsig,  which  niy  own 
sections  confirm,  the  pyramidal  fibres,  after  being  separated  into 
distinct  bundles  in  the  pons,  come  together  so  as  to  form  one 
compact  bundle  in  each  peduncle  {Fig.  166,  P).  This  bundle 
occupies  about  the  middle  third  of  the  crust  of  the  cerebral 
peduncle,  and,  contrary  to  what  has  hitherto  been  believed,  it 
passes  into  the  posterior  segment  of  the  internal  capsule,  lying 
between  the  lenticular  nucleus  and  optic  thalamus  opposite  the 
middle  third  of  the  latter.  The  pyramidal  bundle  is  separated 
from  the  caudate  nucleus  by  a  layer  of  fibres,  which  ascend  from 
the  external  surface  of  the  optic  thalamus  to  reach  the  corona 
radiata,  while  it  rests  on  the  three  successive  segments  of  the 
lenticular  nucleus,  and  reaches  the  corona  radiata  opposite  the 
third  quarter  of  the  caudate  nucleus  (reckoning  from  before 
backwards).  Having  emerged  from  between  the  basal  ganglia, 
without  anywhere  communicating  with  them,  the  fibres  of  the 
pyramidal  bundle  radiate  in  all  directions  towards  the  surface  of 
the  cerebrum,  and  are  mainly  distributed  to  the  central  convo- 
lutions about  the  sulcus  of  Rolando,  the  so-called  "motor  area" 
of  the  cortex  {Fig.  168,  P"). 

The  cardinal  facts  which  concern  us  at  present  are,  that  fibres 
issue  from  the  central  convolutions  of  the  cerebrum,  which  pass 
through  the  internal  capsules  without  communicating  with  the 
basal  ganglia  ;  and  that  the  same  fibres  pass  through  the  cerebral 
peduncles  to  enter  the  pons,  where  they  at  once  begin  to  diminish 
in  number.  The  fibres  of  this  kind,  which  pass  through  the 
pons,  collect  together  to  form  the  anterior  pyramids  of  the 
medulla,  which  also  diminish  in  size  from  above  downwards, 
showing  that  some  of  these  fibres  are  lost  in  the  medulla  itself. 
The  internal  and   by  far  the  larger  portion  of   the   pyramids 


810        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

Fig.   168. 


Bd 
vp Cap 


Fig.  168  (after  Flechsig).    Diagram  of  the  Grey  Masses  of  the  Spinal  Cord  and 
Brain,  showing  the  course  of  the  Conducting  Paths. 

if,  Fissure  of  Rolando. 

P"  P,  T  and  Pt,  Course  of  the  fibres  of  the  pyramidal  tract  from  their  origin  in  the 
central  convolutions  to  their  termination  in  the  anterior  grey  horns  (a,  a'). 

I,  II,  III,  First,  second,  and  third  portions  of  the  lenticular  nucleus  (NL).  NC, 
Caudate  nucleus.       Th,  Optic  thalamus. 

D,  C,  B,  A,  Points  from  which  fibres  issue  connecting  the  cortex  of  the  brain  and 
basal  ganglion,  and  also  the  grey  substance  of  the  pons  [PO).  Bd,  Fibres  con- 
necting the  cerebellum  and  optic  thalamus  ;  and  Caj^,  those  connecting  the 
cerebellum  and  the  grey  substance  of  the  pons. 

aq,  and  jpg'.  Anterior  and  posterior  pair  of  corpora  quadrigemina  respectively. 

X,  Upper,  and  «',  lower  fibres  connecting  the  olivary  body  and  the  corpora  quadri- 
gemina. 

FR,  Formatio  reticularis  of  the  medulla  oblongata,  formed  by  fibres  from  the  optic 


ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION.        811 

decussate  with  one  another,  and  these  portions  pass  backwards 
so  as  to  form  in  the  cord  the  bundles  of  pyramidal  fibres  in  the 
lateral  columns — bundles  which  extend  the  whole  length  of 
the  cord,  but  gradually  diminish  from  above  downwards.  The 
external  and  lesser  portion  of  the  pyramids  pass  directly  down- 
wards to  form  the  columns  of  Tiirck — columns  which  dwindle 
gradually  until  they  disappear,  usually  about  the  middle  of  the 
dorsal  region.  It  is  not  yet  proved  anatomically  how  these 
fibres  end  in  the  cord;  but  other  considerations  render  it  probable 
that  they  end  in  the  grey  matter  of  the  anterior  horns  and  its 
continuation  through  the  medulla,  pons,  and  around  the  aqueduct 
of  Sylvius.  The  pyramidal  fibres,  in  one  word,  form  an  unin- 
terrupted connection  between  the  central  convolutions  of  the 
brain  and  the  central  grey  tube  of  the  cord. 

(6)  The  Accessory  Portion  of  the  Pyramidal  Tract. 

We  have  seen  that  the  accessory  fibres  of  the  pyramidal  tract 
occupy  the  margins  of  the  lozenge-shaped  spaces  into  which  the 
lateral  column  and  column  of  Tiirck  are  divided  {Fig.  151),  and 
th^t  they  are  very  abundant  in  the  portion  of  the  lateral  column 
which  adjoins  the  grey  substance,  and  especially  in  i\ie  formatio 
reticularis.  But  on  ascending  to  the  anterior  pyramid  of  the 
medulla  the  accessory  fibres  become  much  more  abundant,  and 
although  some  of  them  may  still  mix  with  the  other  fibres,  they 
aggregate  in  the  internal  and  anterior  margin  of  the  pyramid, 
so  as  to  occupy  a  circumscribed  area  of  the  pyramid  without 
admixture  with  other  fibres.  This  area  is  shown  in  Figs.  161 
and  162,  p,  which  represent  sections  of  the  medulla  of  a  nine- 
months  embryo.  On  passing  through  the  pons  the  non-medul- 
lated  fibres  occupy  the  inner  portion  of  the  longitudinal  fasciculi 
{Figs.  163  to  165,  p),  pass  to  the  inner  side  of  the  meduUated 


thalamus  {Th),  the  internal  division  of  the  inferior  peduncle  of  the  cerebellum 

{icp)  from  the  spinal  cord  (/?•,  ar,  and  ar'),  and  probably  also  from  the  clavate 

nucleus  (Nc). 
0,  Olivary  body  ;  ecp,  Fibres  of  the  restiform  bodies  connecting  the  olivary  bodies 

and  cerebellum  ;  other  fibres  connect  it  with  the  triangular  {Nprj  and  clavate 

(NC)  nuclei. 
dP,  Decussation  of  the  pyramids. 
pj''.  Fibres  of  the  posterior  roots  which  pass  upwards  and  downwards  into  the  grey 

substance,  and  pursue  only  a  short  course, 
a,  a',  a",  a'",  a"".  Anterior  roots. 
p,  pr,  pr',  pr",  Q,  Fibres  of  the  posterior  roots. 


812         ANATOMICAL   AND   PHYSIOLOGICAL   INTKODUCTION, 

fibres  in  the  crust  of  the  crus  cerebri  {Fig.  166,  lo),  and  reach 
the  cortex  mainly  by  passing  through  the  anterior  half  of  the 
internal  capsule. 

(c)  The  Anterior  Root-zones. 

The  continuation  of  the  anterior  root-zones  through  the 
medulla,  pons,  and  crus,  deserves  special  attention.  The 
course  of  the  fibres  of  these  zones  in  the  medulla  is  obscured 

Fig.  169. 


Fig.  169  (after  Flechsig).    Diagram  of  Transverse  Section  of  the  Spinal  Cord  in  ujyper 
half  of  the  Dorsal  Region, 

C,  Anterior  commissure. 

dd,  Fibres  which  pass  from  the  vesicular  colama  of  Clarke  (re)  to  the  direct 

cerebellar  tract. 
P,  Posterior  horn. 

Figs.  168  and  169  (after  Flechsig).— Letters  common  to  both. 
Ft,  Pyramidal  tract  of  the  lateral  column. 
T,  Columns  of  Tlirck. 
dc,  Direct  cerebellar  tract. 
ar.  Internal  portion  of  the  anterior  root-zone. 
ar'.  External  portion  of  the  anterior  root-zone. 
pr,  Posterior  root-zone. 
G,  G-oll's  columns. 

fr.  Reticular  formation  of  the  spinal  cord. 
a,  Anterior  grey  horns  of  the  spinal  cord. 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.        813 

by  the  fact  that  they  do  not  form  a  defined  mass,  as  in 
the  cord.  They  are  separated  into  bundles  by  the  arcuate 
fibres  of  the  medulla,  so  as  to  form  what  is  called  from  its 
reticular  appearance  the  formatio  reticularis  (Fig.  162,  frs). 
The  zones  consist  of  two  portions,  an  internal,  which  lies  between 
the  anterior  median  fissure  and  the  anterior  roots  (Figs.  152  to 
156,  ar),  and  an  external,  consisting  of  the  remaining  portion 
(Figs.  152  to  156,  ar').  The  internal  portions  of  the  anterior 
root-zones  are  pushed  aside  in  the  lower  part  of  the  medulla  by 
the  decussating  fibres  of  the  pyramidal  tract,  but  above  the 
level  of  the  decussation,  where  the  olivary  body  is  intercalated, 
the  internal  portion  is  thrust  backwards  behind  the  pyramids 
and  close  to  the  median  raph^,  while  the  fibres  of  the  hypo- 
glossal nerve  separate  it  from  the  external  portion.  In  the 
spinal  cord  the  internal  portion  of  the  anterior  root-zone 
maintains  a  close  relation  to  the  internal  group  of  ganglion 
cells,  and  this  relation  is  apparently  maintained  through- 
out its  course  in  the  medulla,  pons,  and  crus.  The  portion 
which  is  called  the  posterior  longitudinal  fasciculus  in  the 
medulla  (Figs.  161  to  165,  L),  pons,  and  crus,  appears  to  be  the 
continuation  upwards  of  the  part  of  the  internal  portion  of  the 
anterior  root-zone  which  adjoins  the  grey  matter,  and  this  fasci- 
culus always  lies  to  the  inner  side  of  the  roots  of  the  anterior 
motor  nerves,  at  their  origin  in  the  motor  ganglion  cells. 

In  the  crus  the  posterior  longitudinal  fasciculus  is  situated  in 
front  of  the  aqueduct  of  Sylvius,  in  close  relationship  with  the 
nucleus  of  origin  of  the  third  nerve  (Fig.  166,  L).  A  portion  of 
this  bundle  is  continued  forwards  in  the  thalamus  in  the  walls 
of  the  lateral  ventricle,  while  the  remaining  fibres  bend  back- 
wards to  join  the  posterior  commissure  of  the  third  ventricle. 
The  fibres  of  the  latter  portion  are  the  first  to  become  medul- 
lated  in  the  cerebrum  of  the  human  embryo. 

The  external  portion  C/f  the  anterior  root-zone  of  the  cord  is 
continued  upwards  into  the  formatio  reticularis  of  the  medulla 
(Figs.  161  and  162,  ar^)  ;  it  lies  behind  the  olivary  body,  and 
comes  to  the  surface  of  the  medulla  in  its  lateral  column,  while 
it  is  bounded  internally  by  the  root  fibres  of  the  anterior  motor 
nerves,  externally  by  the  root  fibres  of  the  nerves  of  the  lateral 
mixed  system,  and  posteriorly  by  grey  matter.     The  interlacing 


814        ANATOMICAL  AND   PHYSIOLOGICAL   INTRODUCTION. 

fibres  of  the  pons  {Figs.  163  to  165,  Tr)  pass  in  front  of  this 
portion  {ar),  and  in  the  crus  it  comes  again  further  forwards, 
so  that  it  is  only  separated  from  the  crusta  by  the  locus  niger 
{Fig.  166,  ar'). 

The  Fillet. — The  portions  of  the  anterior  root-zones  which  are 
remote  from  the  grey  matter,  and  which  lie  next  to  the  inner 
and  posterior  surfaces  of  the  olivary  body  in  the  medulla,  and  to 
the  transverse  interlacing  fibres  in  the  pons  {Figs.  161  and  165, 
ar  and  ar),  are  named  the  fillet.  It  is  divided  into  an  internal 
and  an  external  portion  corresponding  to  the  internal  and  ex- 
ternal division  of  the  anterior  root-zone.  The  internal  portion  lies 
to  the  inner  side  of  the  olivary  body,  a  portion  of  it  even  coming 
in  front  of  it,  and  interposing  between  it  and  the  anterior  pyramid 
{Fig.  162,  ar)  at  the  lower  end  of  the  pons.  When  the  olivary 
body  has  disappeared,  this  portion  of  the  fillet  is  pushed  back- 
wards so  as  to  join  the  external  portion,  and  both  divisions  now 
lie  behind  the  transverse  fibres  of  the  pons.  The  fibres  of  the 
internal  division  of  the  fillet  seem  to  pass  upwards  to  become 
connected  with  the  optic  thalamus,  while  those  of  the  external 
division  {Fig.  168,  x'  and  x)  subdivide  into  an  outer  and  an 
inner  bundle,  the  former  of  which  terminates  in  the  posterior, 
and  the  latter  in  the  anterior  ganglion  of  the  corpora  quadri- 
gemina  {Fig.  167,  p/). 

{d)  The  Direct  Cerebellar  Tract. 

The  direct  cerebellar  fibres  are  represented  by  a  thin  lamella  of 
longitudinal  fibres  lying  on  the  surface  of  the  cuneate  fasciculus 
and  of  the  grey  tubercle  of  Rolando  {Figs.  161  and  162,  dc). 
They  pass  upwards  to  the  cortex  of  the  cerebellum,  and  thus 
form  an  uninterrupted  connection  between  its  grey  matter  and 
the  cord,  where  the  fibres  are  supposed  to  pass  inwards  between 
the  bundles  of  the  pyramidal  fibres  of  the  lateral  columns,  to 
terminate  in  the  cells  of  the  vesicular  column  of  Clarke. 

(e)  Columns  of  Goll  and  Posterior  Root-zones. 

A  transverse  section  of  the  lower  half  of  the  medulla  shows 
that  the  columns  of  Goll  are  continued  upwards  into  the  medulla 
in  the  form  of  two  bundles  of  fibres,  one  on  each  side  of  the 
posterior  median  fissure.     Each  bundle  contains  a  nucleus  of 


ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION.        815 

grey  matter,  which  from  its  form  is  called  the  clavate  nucleus, 
and  the  bundle  itself  is  called  the  pyramidal  column,  or  fasci- 
culus gracilis  (Fig.  159,  G,  en);  the  whole  of  the  fibres  of  this 
column  appear  to  terminate  in  the  clavate  nucleus.  External  to 
this  fasciculus  is  placed  a  wedge-shaped  bundle,  called  the 
fasciculus  cuneatus,  holding  in  its  interior  a  grey  nucleus,  called 
from  its  form  the  triangular  nucleus  (Fig.  159,  pr,  tn).  The 
larger  portion  of  the  fibres  of  the  posterior  root-zone  of  the  cord 
terminates  in  the  cuneate  fasciculus  and  its  enclosed  grey  nucleus, 
but  a  smaller  portion  is  continued  upwards  through  the  medulla 
and  pons  in  the  form  of  two  separate  bundles  of  white  sub- 
stance—the ascending  root  of  the  fifth  (Figs.  159  to  163,  at) 
and  the  fasciculus  rotundus  (Figs.  159  to  162,  /).  The  slender 
and  cuneate  fasciculi  of  the  medulla  are  much  larger  in  size 
than  the  column  of  Goll  and  posterior  root-zone  of  the  cord, 
owing  to  the  interposition  of  the  grey  nuclei ;  hence  the  pos- 
terior horn  of  grey  matter  is  displaced  outwards  and  forwards 
in  the  medulla,  so  that  the  continuation  of  the  gelatinous  sub- 
stance forms  a  mass  of  grey  matter  on  the  lateral  aspect  of  the 
medulla,  known  as  the  grey  tubercle  of  Rolando  (Fig.  159,  sg). 
This  mass  of  grey  matter  is  continued  upwards  in  the  medulla 
and  pons  to  the  level  of  the  point  of  emergence  of  the  fifth 
nerve,  and  gives  origin  to  the  ascending  root  of  the  latter.  In 
close  relationship  with  the  external  surface  of  this  grey  mass  is  a 
bundle  of  longitudinal  nerve  fibres  which  are  medullated  in  a 
nine-months  embryo,  and  which  must  be  regarded  as  the  homo- 
logue  in  the  medulla  of  the  posterior  root-zone  of  the  cord.  A 
somewhat  similar  bundle  of  fibres  is  in  close  relationship  with 
the  mass  of  grey  matter  known  as  the  descending  root  of  the 
fifth  nerve  (Figs.  164  and  165,  dt),  and  it  also  must  be  regarded 
as  representing  the  posterior  root-zone.  The  fasciculus  rotundus 
(Figs.  159  to  162,/)  is  a  bundle  of  longitudinally- disposed  fibres, 
which  have  become  detached  from  the  posterior  root-zone  in  the 
upper  part  of  the  cervical  region  of  the  cord.  This  bundle, 
which  has  been  named  the  "  ascending  root  of  the  lateral  mixed 
system  "  by  Meynert,  and  the  "  respiratory  fascicle  "  by  Krause, 
is  continued  upwards  as  far  as  the  upper  end  of  the  nucleus  of 
the  glosso-pharyngeal  nerve.  It  maintains  a  close  relationship 
with  the  nucleus  of  origin  of  the  sensory  roots  of  the  lateral 


816        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION, 

mixed  system  of  nerves,  and  it  likewise  must  be  regarded  as  an 
upward  continuation  of  the  posterior  root-zone  of  the  spinal 
cord.  The  white  substance  of  the  ascending  and  descending 
roots  of  the  fifth  nerve  and  the  fasciculus  rotundus  appear, 
therefore,  to  be  the  homologues  of  the  posterior  root-zone  of  the 
spinal  cord — a  mere  upward  continuation  of  these  zones,  after 
what  belongs  to  the  spinal  portion  of  the  central  grey  tube  has 
terminated  in  the  triangular  nucleus. 

One  of  the  most  remarkable  rearrangements  of  fibres  in  the 
medulla  arises  from  the  fact  that  the  cuneate  fasciculus,  through 
the  intermediation  of  its  nucleus,  resolves  itself  into  arcuate 
fibres,  which  pass  forwards  and  upwards  to  the  nucleus  of  the 
olivary  body  on  the  same  side  {Fig.  168,  Npr);  and  it  is  also 
probable  that  the  slender  fasciculus  has  a  similar  termination. 

(/)  Sensory  Conducting  Paths. 
The  posterior  nerve  root  enters  the  cord  as  a  single  bundle, 
and  immediately  its  fibres  diverge  in  various  directions.  The  fan 
formed  by  the  diverging  fibres  on  horizontal  section  may,  for  the 
purposes  of  description,  be  divided  into  three  bundles.  The  fibres 
of  the  middle  bundle  pass  directly  into  the  substantia  gelatinosa 
of  the  posterior  grey  horn,  and  those  of  the  outer  bundle  pass 
along  the  external  border  of  the  posterior  horn  near  the  lateral 
column,  whilst  those  of  the  inner  bundle  pass  between  the  longi- 
tudinal fibres  of  the  posterior  root-zone  and  enter  the  grey  sub- 
stance of  the  posterior  horn  in  front  of  the  substantia  gelatinosa. 
On  a  longitudinal  section  of  the  spinal  cord  made  parallel  with 
the  fibres  of  the  posterior  root  at  its  point  of  junction  with  the 
cord,  the  fibres  may  be  also  seen  to  diverge  in  the  form  of  a  fan, 
some  of  them  passing  into  the  cord  horizontally,  while  others 
pass  upwards  and  downwards  before  becoming  lost  in  the  grey 
matter.  The  fibres  which  pass  downwards  before  entering  the 
grey  matter  are  chiefly  found  in  what  we  have  described  as  the 
middle  bundle  on  horizontal  section.  The  course  of  the  fibres 
of  the  posterior  roots  after  their  passage  into  the  posterior  grey 
horns  has  not  been  well  ascertained  by  anatomists,  but  physio- 
logical experiments  and  pathological  observations  show  that  most, 
if  not  all,  of  them  cross  over  to  the  opposite  half  of  the  cord 
{Fig.  170,  S,  S^),  and  there  ascend  to  reach  the  cortex  of  the 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.        817 

posterior  lobes  of  the  brain  {Fig.  170,  3',  3).  The  fibres  of 
the  posterior  roots  do  not  probably  pass  upwards  to  the  cortex 
in  unbroken  continuity;  it  is  much  more  likely  that  sensory 
conduction  is  effected  by  means  of  a  combined  system  of  cells 
and  fibres.  The  decussation  of  the  sensory  tracts  most  probably 
takes  place  in  the  posterior  commissure.  It  is  likely  that  what 
I  have  called  the  middle  bundle  of  the  posterior  root,  on  hori- 
zontal section,  ascends  in  the  posterior  grey  horn  of  the  opposite 
side ;  the  outer  bundle  on  reaching  the  opposite  side  passes 
upwards  in  close  proximity  to  the  lateral  pyramidal  tract ;  and 
the  inner  bundle  seems  to  pass  upwards  in  or  near  to  the 
posterior  root -zone  of  the  opposite  side  (Fig.  170,  3',  4').  The 
posterior  column  of  the  lumbar  region  is  said  to  contain  only  the 
conducting  paths  of  touch  for  the  pelvic  region,  sexual  organs, 
perinseum,  and  anal  region,  whilst  the  sensory  paths  of  the  lower 
extremities  are  supposed  to  lie  at  first  in  the  lateral  columns, 
and  only  to  enter  the  posterior  columns  after  they  have  reached 
a  higher  level.  But  although  this  statement  may  be  true  with 
regard  to  the  spinal  cord  of  the  rabbit,  it  does  not  appear  to  be 
applicable  to  the  human  cord.  Some  anatomists  believe  that  a 
portion  at  least  of  the  sensory  conducting  path  passes  upwards  on 
the  same  side  as  the  root  from  which  it  is  derived,  and  a  middle 
and  a  superior  decussation  of  sensory  fibres  have  been  described, 
both  of  which  are  supposed  to  take  place  in  the  medulla  oblongata. 
Meynert  believes  that  a  decussation  of  sensory  fibres  takes  place 
in  the  lower  part  of  the  medulla  oblongata.  The  sensory  fibres 
issue  from  the  triangular  and  clavate  nuclei  of  one  side,  and 
pursue  an  arcuate  course  round  the  central  grey  column  to  reach 
the  anterior  pyramid  of  the  opposite  side,  and  become  mixed  in 
their  course  with  the  decussating  fibres  of  the  lateral  column. 
After  decussating  the  sensory  fibres  are  described  as  occupying 
the  external  and  posterior  aspect  of  the  anterior  pyramid,  and 
thence  ascend  to  form  a  portion  of  the  longitudinal  fibres  of  the 
pons.  Flechsig,  however,  asserts  that  these  fibres  curve  round 
the  olivary  body  of  the  same  side  and  enter  its  substance.  The 
most  recent  observations  with  regard  to  the  crossing  of  sensory 
fibres  have  been  made  by  Debove  and  Gombault.^    In  a  case  of 

*  Debove   and  G-ombanlt.      "  Note   sur  rentrecroisemeut  sensitif   du    oulbe." 
Arch,  de  Neurologie,  Tome  I.,  1880-81,  p.  5. 

VOL.  L  AAA 


818        ANATOMICAL   AND   PHYSIOLOGICAL   INTRODUCTION. 


Fig.  170. 


Fig.  170  f after  Bramwell')-  Diagram  of  the  Spinal  Segment  as  a  Centre  and  Con' 
ducting  Medium.— B,  right,  and  B',  left  hemispheres  of  the  brain ;  M  0,  lower 
end  of  the  medulla  oblongata  ;  1,  the  motor  tract  from  the  right  hemisphere ;  it 
divides  at  M  O,  and  the  larger  portion  crosses  over  to  the  opposite  side  and 
passing  down  the  lateral  column  it  supplies  the  muscles  M  and  M'  on  the  left 
side  of  the  body.  The  supply  to  M  is  given  off  at  1'.  The  smaller  portion 
passes  down  the  anterior  column  of  the  same  side,  and  supplies  the  muscles  m 
and  m'  on  the  right  side  of  the  body  ;  2,  the  motor  tract  on  the  left  side  of  the 
body ;  the  larger  portion  crosses  over  to  the  opposite  side  and  supplies  the 
muscles  M*  and  M'^  on  the  right  side  of  the  body,  while  the  lesser  portion  passes 
down  the  same  side  and  supplies  the  muscles  wz*  and  m^  on  the  left  side  of  the 
body.  S,  S',  sensory  areas  on  the  left  side  of  the  body ;  3',  3,  the  main  sensory 
tract  from  the  left  side  of  the  body ;  it  passes  up  on  the  opposite  side  (right)  of 
the  cord  in  the  postero-external  column,  and  proceeds  to  the  right  hemisphere  of 
the  brain;  S*,  S',  sensory  areas  of  the  right  side  of  the  body;  4',  4,  the  main 
sensory  tract  from  the  right  side  of  the  body,  proceeding  up  the  left  side  of  the 
cord  to  the  left  hemisphere  of  the  brain.  The  arrows  indicate  the  direction  of 
the  conduction. 

*  Bramwell  (Byrom).    The  diseases  of  the  spinal  cord.    1882.    p.  14, 


ANATOMICAL   AND   PHYSIOLOGICAL   INTEODUCTION.        819 

amyotrophic  lateral  sclerosis,  in  which  the  motor  fibres  of  the 
anterior  pyramids  of  the  medulla  oblongata  had  undergone 
degeneration,  the  sensory  fibres  at  the  inferior  crossing  were  seen 
after  decussating  to  divide  into  small  fasciculi,  which  penetrated 
the  posterior  and  external  surface  of  the  anterior  pyramid,  and 
soon  became  lost  amongst  the  motor  fibres.  A  little  higher  up 
the  greater  portion  of  the  sensory  fibres  pass  into  the  middle 
part  of  the  posterior  surface  of  the  pyramid,  while  the  lesser 
portion  of  them  become  lost  amongst  the  fibres  of  the  stratum 
zonale.  At  the  superior  part  of  the  sensory  crossing  the  fibres  on 
decussating  pursue  two  different  courses.  The  most  superficial  of 
them  penetrate  the  external  part  of  the  posterior  surface  of  the 
pyramid  and  become  lost  amongst  the  motor  fibres,  whilst  those 
which  lie  deepest  pass  to  the  posterior  and  external  angle  of  the 
pyramid  and  there  curve  upwards  to  reach  the  pons  as  a  more  or 
less  separate  bundle.  Most  of  the  fibres  described  by  Debove  and 
Gombault  are  well  seen  in  my  own  sections  of  the  embryo,  but  I 
have  always  regarded  them  as  being  derived  from  the  external 
portion  of  the  inner  division  of  the  inferior  peduncle  of  the  cere- 
bellum, and  I  am  by  no  means  satisfied  that  their  functions  are 
sensory.  It  is  at  least  certain  that  a  circumscribed  lesion  of  the 
restiform  body  produces  a  crossed  hemiansesthesia,  in  which  the 
face  is  implicated  on  the  same  side  as  the  lesion  and  the  half  of 
the  body,  and  the  extremities  on  the  opposite  side. 


Fig.  171. 


x^-'v, 


F3/\ 


Fig.  171  (after  Debove  and  Gombault).  Section  of  the  Anterior  Pyramid  (P)  of  the. 
Medulla  Oblongata,  on  a  level  with  the  middle  part  of  the  crossing  of  the  Sensory 
Fibres. — FS,  Sensory  Fibres  ;  FSA,  Posterior  and  external  sensory  fasciculus 
which  does  not  penetrate  into  the  substance  of  the  pyramid ;  E,  Crossing  of  the 
sensory  fibres  ;  0,  Nucleus  of  the  pyramid ;  Z,  Stratum  zonale. 


820        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

(2)  TTie  Superadded  White  Substance  of  the  Medulla  Oblongata 

and  Pons. 

§  367.  The  superadded  white  substance  of  the  medulla 
oblongata  and  pons  consists  chiefly  of  the  fibres  which  unite 
them  with  the  cerebellum.  These  fibres  are  collected  into  three 
separate  bundles  for  each  side,  which  constitute  the  peduncles 
of  the  cerebellum,  and  we  have  therefore  to  describe  (a)  the 
inferior,  (&)  the  middle,  and  (c)  the  superior  peduncles. 

(a)  The  Inferior  Peduncles. 

The  inferior  peduncle  of  the  cerebellum,  according  to  Stilling, 
breaks  up,  on  entering  the  medulla,  into  an  internal  {Fig.  162,  ep) 
and  an  external  {Fig.  162,  ip)  division,  the  latter  of  which  he 
called  the  "  restiform  body."  The  fibres  of  the  internal  division 
spring  from  the  roof-nuclei  of  Stilling,  and  on  reaching  the  medulla 
resolve  themselves  into  arcuate  fibres,  which  pass  downwards 
and  inwards,  interlacing  with  the  ascending  fibres  of  the  anterior 
root-zone  behind  the  olivary  body  of  the  same  side  ;  some  anato- 
mists believe  that  they  cross  the  median  raph^  to  reach  the 
olivary  body  of  the  opposite  side.  The  fibres  of  the  restiform 
body  are  derived  from  the  cortex  of  the  cerebellum,  and  from  a 
layer  of  fibres  surrounding  the  dentate  nucleus;  this  division, 
on  descending  to  the  medulla,  subdivides  into  two  bundles, 
which  are  separated  from  one  another  by  the  direct  cerebellar 
fibres  of  the  lateral  columns  of  the  cord  in  their  ascent  towards 
the  cerebellum  {Fig.  162,  dc).  In  a  nine-months  human  embryo 
the  fibres  of  the  restiform  body  are  non-medullated  {Fig.  162,  ep); 
while  those  ascending  from  the  lateral  columns  are  medullated 
{Fig.  162,  dc),  so  that  the  two  sets  can  be  readily  distinguished 
from  one  another.  The  fibres  of  the  restiform  body,  like  those 
of  the  internal  division  of  the  peduncle,  resolve  themselves  into 
arcuate  fibres,  the  external  bundle  forming  the  zonular  layer 
which  passes  in  front  of  the  olivary  body,  and  the  fibres  of  which 
reach  the  median  raph^  by  passing  both  in  front  and  behind  the 
anterior  pyramid.  Those  which  pass  in  front  of  the  anterior 
pyramid  are  called  arciform  fibres  {Fig.  162,  a);  they  wind 
backwards  to  reach  the  median  raph^  {Fig.  172),  where,  after 
decussating  with  the  corresponding  fibres  of  the  opposite  side, 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.         821 

they  bend  outwards  to  reach  the  olivary  body  of  the  opposite 
side  where  they  terminate.  A  great  part  of  the  arcuate  fibres  of 
the  internal  bundle  seem  to  pass  through  the  olivary  body  of  the 
same  side  without  being  connected  with  its  grey  substance ;  and 
after  gaining  the  raphe  they  also  cross  over  to  pass  into  the 
interior  of  the  olivary  body  of  the  opposite  side,  in  the  grey  sub- 
stance of  which  all  the  arcuate  fibres  of  the  restiform  body 
terminate.  The  olivary  body,  therefore,  is  the  medium  of  com- 
munication between  the  cuneate  fasciculus  and  probably  also  the 
slender  fasciculus  of  the  same  side  on  the  one  hand,  and  the 
restiform  body  and  probably  the  internal  division  of  the  cere- 
bellar peduncle  of  the  opposite  side  on  the  other  hand. 

(6)  The  Middle  Peduncles  of  the  Cerebellum. 

The  fibres  of  the   middle  peduncle   of  the   cerebellum  are 
derived  from  the  cortex ;  they  pass  in  front  of  and  through  the 


Fig.  172. 


tba 

Fig.  172  (after  Henle).  Diagram  of  a  horizontal  section  of  the  anterior  part  of  the 
median  raphe  of  the  Medulla  Oblongata.— 'F-py,  Anterior  pyramid;  Fba,  Fibrse 
arciformes. 


822        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

substance  of  the  pons  {Figs.  163  to  165,  Tr  and  Tr'),  where 
they  separate  the  ascending  fibres  of  the  anterior  pyramids  into 
bundles  (Figs.  163  to  165,  P,  p),  and  interlace  in  the  middle 
line  with  the  fibres  of  the  middle  peduncle  of  the  opposite  side. 
On  reaching  the  opposite  side  they  are  supposed  to  terminate  in  the 
cells  of  interposed  grey  matter,  by  means  of  which  they  are 
connected  with  fibres  descending  from  the  crusta.  The  close 
relationship  of  the  middle  peduncles  with  the  lateral  lobes  of 
the  cerebellum  is  well  illustrated  by  the  fact  that  in  those 
animals  in  which  the  latter  are  deficient  or  absent  the  transverse 
fibres  of  the  pons  are  few  or  entirely  wanting. 

(c)  The  Superior  Peduncles  of  the  Cerebellum. 

The  fibres  of  the  superior  peduncles  are  derived  from  the 
dentate  nuclei ;  they  decussate  with  one  another  in  the  tegmen- 
tum, the  fibres  of  one  side  passing  over  to  be  connected  with  the 
red  nucleus  of  the  opposite  side  (Fig.  166,  x).  The  fibres  of  the 
superior  peduncles  are  medullated  in  .a  nine-months  embryo ; 
they  may  be  seen  surrounding,  and  even  in,  the  substance  of  the 
red  nucleus  (Fig.  166,  RN),  and  a  considerable  proportion  of  them 
pass  upwards  uninterruptedly  to  end  in  the  inferior  and  external 
surface  of  the  thalamus,  or,  as  I  am  inclined  to  believe,  pass  un- 
interruptedly along  its  external  border  upwards  to  be  connected 
with  the  central  convolutions  of  the  cortex  of  the  cerebrum. 

Some  anatomists  think  that  part  of  the  fibres  of  tbe  anterior 
root -zones  pass  through  the  crusta  to  join  the  lenticular  nuclei ; 
but  a  very  important  fact  has  been  ascertained  by  Flechsig, 
which  renders  this  doubtful.  Flechsig  found  that  in  a  nine- 
months  human  embryo  the  pyramidal  fibres  in  the  crusta  are 
the  only  ones  which  have  acquired  a  medullary  sheath ;  and  my 
own  sections  confirm  this  (Fig.  166,  P).  But  the  fibres  of  the 
anterior  root-zones  in  the  cord  are  medullated  at  a  very  early 
period  of  development,  and  long  before  the  pyramidal  fibres  have 
acquired  a  medullary  sheath;  hence  it  may  be  inferred  that  none 
of  the  fibres  of  the  anterior  root-zones  pass  up  into  the  crusta  or 
motor  tract  of  the  crura,  although  it  is  very  probable  that  new 
fibres  become  developed,  which  connect  the  corpora  striata  and 
the  cord,  and  that  these  pass  through  the  crusta  and  become 
mixed  with  the  fibres  of  the  anterior  root-zones. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.        823 

II. -THE  PHYSIOLOGY  OF  THE  SPINAL  CORD  AND  MEDULLA 

OBLONGATA. 

It  would  occupy  too  mucli  space  to  describe  fully  tlie  func- 
tions of  the  spinal  cord  and  medulla  oblongata,  and  the  reader 
is  referred  to  physiological  manuals  for  the  usual  information 
on  the  subject.  My  main  object  at  present  is  to  elicit  a  few 
points  which  will  be  of  subsequent  use  to  us  in  interpreting  the 
phenomena  of  disease,  and  in  connecting  symptoms  with  morbid 
alterations  of  structure.  It  is  unnecessary  to  enter  upon  a 
separate  consideration  of  the  physiology  of  the  spinal  cord,  and 
of  the  medulla  oblongata  and  pons,  inasmuch  as  both  organs 
discharge  essentially  the  same  functions.  But  we  have  already 
seen  that  the  cranial  segments  of  the  spinal  axis  contain  masses 
of  nervous  tissue  which  are  not  represented  in  the  cord,  and  we 
may  infer  that  these  superadded  tissues  will  discharge  super- 
added functions.  Our  subject  may,  therefore,  be  divided  into 
the  functions  of,  (A)  the  spinal  axis  throughout  its  whole  extent 
from  the  conus  medullaris  to  the  tuber  cinereum,  and  (B)  the 
nervous  masses  which  are  superadded  to  the  cranial  portion  of 
the  spinal  axis,  and  which  do  not  belong  to  the  spinal  system. 

(A)  The  Functions  of  the  Spinal  Axis. 

The  spinal  cord  may  be  regarded  as  a  series  of  ganglionic 
centres,  and  as  a  conducting  medium,  the  former  function  being 
discharged  by  the  grey  matter,  and  the  latter  chiefly,  although 
not  entirely,  by  the  white  substance.  Our  chief  object  in  this 
place  being  to  connect  action  as  much  as  possible  with  structure, 
we  shall  divide  the  functions  of  the  spinal  axis  into  those  of  (l) 
the  grey,  and  (ii.)  the  white  substance. 

(I.)  THE  FUNCTIONS  OF  THE  GREY  SUBSTANCE. 

We  shall  not  attempt  any  scientific  classification  of  the 
functions  of  the  grey  substance  of  the  spinal  cord,  but  shall 
consider  (1)  the  reflex,  (2)  the  automatic,  (3)  the  trophic,  (4)  the 
vaso-motor  and  secretory  functions,  and  shall  endeavour  to  con- 
nect them  with  the  groups  of  ganglion  cells  of  the  anterior 
horns  and  the  vesicular  column  of  Clarke.  We  shall  then  make 
a  few  remarks  on  the  functions  of  (5)  the  posterior  grey  horns, 


824        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

(6)  the  central  grey  column,  (7)  the  motor  ganglion  cells  when 
acting  in  subordination  to  the  cortical  centres,  and  (8)  the  special 
nuclei  of  the  cranial  portion  of  the  spinal  axis. 

(1)  Reflex  Action. 

§  868.  The  production  of  reflex  action  is  one  of  the  earliest 
and  most  fundamental  functions  of  the  spinal  cord.  As  we 
have  already  seen,  every  reflex  act  requires  for  its  performance 
an  afferent  and  an  efferent  fibre,  and  a  centre.  The  earlier- 
formed  ganglion  cells  of  the  anterior  grey  horns  constitute  the 
centres  of  reflex  action;  and  it  is  probable  that  the  reflex 
afferent  fibres  pass  to  them  directly,  without  the  intervention  of 
the  grey  substance  of  the  posterior  horns.  Inasmuch  as  the 
reflex  afferent  fibres  are  formed  at  an  early  period  in  the  de- 
velopment of  the  cord,  they  must  be  thrust  out  laterally  during 
the  development  of  the  posterior  grey  horn,  so  that  they  will 
occupy  an  external  position  in  the  fan  formed  by  the  spreading 
out  of  the  fibres  of  the  posterior  roots.  We  have  already  seen 
that  there  are  grounds  for  believing  that  the  afferent  fibres  of 
the  reflex  arcs  which  maintain  the  muscular  tonus  upon  which 
the  tendon-reactions  depend  pass  in  the  inner  radicular  fasci- 
culus, and  it  is  not  improbable  but  that  the  afferent  fibres  of  the 
cutaneous  reflexes  pass  in  the  outer  radicular  fasciculus.  The 
efferent  reflex  fibres  pass  out  in  the  anterior  roots,  and  the  same 
fibres  probably  convey  both  reflex  and  voluntary  impulses. 

(2)  Automatic  Action. 
§  369.  The  spinal  cord  contains  a  considerable  number  of 
what  have  been  regarded  as  automatic  centres,  but  it  is 
probable  that  many  of  these  act  in  a  reflex  manner.  The 
lumbar  portion  of  the  cord  contains  centres  for  the  regulation 
of  the  acts  connected  with  micturition,  defecation,  erection  and 
ejaculation,  and  parturition.  The  oculo-pupillary  centres  in  the 
upper  dorsal  and  cervical  regions  of  the  cord  have  already  been 
described. 

(3)  Trophic  Function  of  the  Cord. 

§  370.  It  is  well  known  that  the  ganglion  cells  of  the  anterior 
horns  of  the  cord  exercise  a  trophic  influence  on  the  muscles ; 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.        825 

but  whether  there  are  trophic  cells  endowed  with  special 
functions,  or  whether  all  the  cells  are  endowed  with  both  motor 
and  trophic  functions,  I  am  unable  to  say.  With  some  degree 
of  qualification,  I  feel  inclined  to  adopt  the  latter  view. 

It  is  well  known  that  within  certain  limits,  increased  func- 
tional activity  of  a  muscle  is  followed  by  an  increase  in  its  bulk, 
and,  conversely,  that  a  diminution  of  its  activity  is  followed  by 
diminution  of  its  bulk.  When,  therefore,  the  mechanism  in  the 
cord,  which  regulates  the  movements  of  the  muscle,  is  in  a  state 
of  activity,  this  is  followed  by  an  increase  in  the  function  of  the 
muscle,  and  consequently  by  an  increase  in  its  bulL  If,  in 
addition  to  an  increase  in  its  bulk,  the  muscle  be  called  upon  to 
make  a  new  adjustment  in  response  to  altered  circumstances,  the 
new  adjustment  can  only  become  permanent  in  the  race  when  it 
is  organised  in  the  cord  by  the  growth  of  new  cells  and  fibres  in 
addition  to  the  original  mechanism  by  which  its  movements 
were  guided.  But  if  the  new  cells  and  fibres  become  incapaci- 
tated from  any  cause,  the  muscle  will  soon  lose  the  structural 
modification  which  corresponded  to  its  recently-acquired  func- 
tional adjustment,  but  no  other  change  will  take  place  in  it. 
As  long  as  the  original  mechanism  is  maintained  in  the  cord,  so 
long  will  the  nutrition  of  the  great  bulk  of  the  muscle  go  on  as 
before.  But  the  case  is  very  different  when  the  function  of  the 
original  mechanism  is  destroyed ;  then  the  nutrition  of  the 
muscle  is  injured  at  its  very  foundation,  and  profound  trophic 
changes  occur.  It  is  very  probable,  therefore,  that  the  influence 
exerted  by  the  later-developed  ganglion  cells  of  the  anterior 
horns  on  the  nutrition  of  the  muscles  is  small,  while  that  of  the 
earlier-developed  cells  is  very  great.  Pathological  observations 
render  it  probable  that  the  ganglion  cells  of  the  anterior  horns 
exercise  a  controlling  influence  upon  the  nutrition  of  the  bones 
and  joints,  while  those  of  the  posterior  horns  stand  in  a  similar 
relation  to  the  nutrition  of  the  skin  and  its  appendages. 

(4)  Vaso-motor  and  Secretory  Functions. 

§  871.  Vaso-motor  centres  exist  in  the  cord  by  means  of  which 
the  tonus  of  the  muscular  coat  of  the  vessels  is  maintained.  It 
has  been  thought  that  the  spinal  cord  also  exercises  a  tonic 
action  over  the  skeletal  muscles,  but  this  opinion  is  doubtful. 


826        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 

The  tone  of  the  sphincters  of  the  bladder  and  rectum,  however, 
is  undoubtedly  maintained  by  the  lumbar  part  of  the  cord,  and  is 
probably  reflex  in  character.  The  peristaltic  movements  of  the 
oesophagus,  stomach,  and  intestines  are  regulated  by  the  central 
grey  tube,  and  we  have  already  seen  that  the  secretions  of 
glands  are  also  controlled  by  the  spinal  centres.  Little  is  known 
beyond  conjecture  of  the  localisation  of  the  centres  of  visceral 
innervation  in  the  cord.  That  they  are  not  situated  in  the 
anterior  grey  horns  is  rendered  certain  by  the  fact  that  the 
visceral  movements,  and  the  automatic  actions  of  defecation, 
micturition,  erection,  and  parturition  remain  unaffected  in  disease 
limited  to  the  anterior  grey  horns. 

Several  considerations  may  be  adduced  tending  to  show  that 
the  vesicular  column  of  Clarke  contains  the  spinal  centres  of 
visceral  innervation.  The  cells  of  this  column  are  bipolar,  like 
those  of  the  sympathetic,  and  not  multipolar,  like  those  of  the 
anterior  horns  which  regulate  the  complicated  actions  of  the 
skeletal  muscles.  This  column  is  absent  in  the  lumbar  and 
cervical  enlargements,  the  portions  of  the  cord  which  supply 
nerves  to  the  limbs,  and  in  the  upper  half  of  the  cervical  region 
which  supplies  nerves  to  the  muscles  of  the  neck.  It  is,  on  the 
other  hand,  present  in  the  upper  lumbar  and  the  dorsal  regions 
of  the  cord — the  portions  from  which  the  trunk  is  innervated, 
and  is  again  represented  in  the  medulla  oblongata  as  the  prin- 
cipal nucleus  of  origin  of  the  vagus — the  most  important  visceral 
nerve  of  the  body.  It  may  be  assumed  that  all  the  actions 
regulated  through  the  vesicular  column  of  Clarke  are  subor- 
dinated to  the  highest  expanded  portion  of  it  which  constitutes 
the  nucleus  of  the  vagus ;  hence  there  is  no  reason  to  assume 
that  the  medulla  oblongata  contains  a  circumscribed  vaso-motor 
centre  distinctly  separated  from  the  nucleus  of  the  vagus. 

(5)  Functions  of  the  Posterior  Grey  Horns  and  Posterior 

Roots. 

§  372.  Afferent  impulses  are  conducted  to  the  spinal  cord  by 
the  posterior  roots.  As  already  remarked,  it  is  probable  that  the 
afferent  impulses,  which  have  undergone  the  highest  organi- 
sation in  the  cord,  are  conducted  by  the  fibres  which  occupy  the 
periphery  of  the  fan,  formed  by  the  spreading  out  of  the  fibres 


ANATOMICAL   AND  PHYSIOLOGICAL   INTRODUCTION.        827 

of  the  posterior  roots  as  they  enter  the  substance  of  the  cord. 
In  the  anterior  horns  the  most  specialised  actions  are  repre- 
sented, partly  by  the  development  of  new  processes  to  the 
existing  ganglion  cells,  and  partly  by  the  growth  of  additional 
cells;  but  in  the  posterior  horns  the  fibres,  which  conduct  the 
most  specialised  impulses,  have  become  adapted  to  their  func- 
tions by  the  gradual  development  in  connection  with  them  of 
special  peripheral  terminal  organs  on  the  one  hand,  and  central 
terminal  organs  on  the  other.  The  stimulation  of  certain  fibres 
in  an  early  stage  of  development  may  give  rise  only  to  diffused 
and  irregular  contractions,  while  at  a  higher  stage  of  development 
complicated  and  apparently  purposive  reflex  movements  are  pro- 
duced by  a  similar  stimulation;  again,  a  stimulation  which  at  an 
early  stage  of  development  gives  rise  only  to  a  diffused  sensation 
of  pain,  may  at  a  higher  stage  of  development  evoke  intellectual 
sensations  of  touch  and  temperature.  It  may,  therefore,  be 
expected  that  the  fibres  which  conduct  reflex  impulses,  and  those 
that  conduct  the  impulses  which  on  reaching  the  cortex  of  the 
brain  give  rise  to  the  intellectual  sensations,  will  occupy  the 
periphery  of  the  fan  of  the  posterior  roots ;  while  those  which 
conduct  the  impulses  which  on  reaching  the  cortex  give  origin  to 
the  common  or  emotional  sensations  will  occupy  its  centre.  We 
have  already  seen  reason  for  believing  that  the  afferent  fibres  of 
the  arc  of  the  tendon-reactions  pass  through  the  internal  radicular 
fasciculus  to  reach  the  posterior  horn,  and  it  is  probable  that  the 
afferent  fibres  of  the  sense  of  touch  and  locality  also  pass  through 
the  same  fasciculus.  We  have  also  supposed  that  the  cutaneous 
reflex  fibres  pass  through  the  external  radicular  fasciculus,  and 
it  is  probable  that  the  afferent  fibres  of  the  sense  of  temperature 
likewise  pass  through  this  bundle.  The  afferent  fibres  of  the 
common  sensation  of  pain  pass  through  the  centre  of  the  pos- 
terior roots  directly  into  the  grey  matter  of  the  posterior  horns. 

Section  of  the  white  posterior  column  destroys  the  sensation 
of  touch  permanently  in  the  regions  situated  below  the  section, 
but  leaves  the  sensation  of  pain  unaffected ;  and,  conversely, 
section  of  the  entire  grey  substance,  leaving  the  posterior  columns 
intact,  destroys  the  sense  of  pain  and  leaves  that  of  touch  (Schifif). 

A  retardation  of  the  conduction  of  sensation  occurs  when  the 
posterior  grey  horns  are  cut,  and  the  more  the  grey  substance  is 


828        ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


diminished  the  more  marked  is  the  retardation.  The  sensory 
conducting  paths  decussate  in  the  cord  soon  after  the  root 
fibres  enter  it,  but  considerable  difference  of  opinion  exists  as  to 
the  mode  and  extent  of  this  decussation  with  regard  to  the  con- 
ducting paths  of  the  different  kinds  of  sensation.  Brown- 
S^quard  states  that  the  conducting  paths  of  the  various  forms  of 
cutaneous  sensibility  cross  at  different  heights,  those  coaducting 
sensations  of  temperature  crossing  somewhat  earlier  than  the 
rest.  He  also  believes  that  the  paths  for  the  different  forms  of 
sensibility  are  separated  from  one  another  in  their  further  course. 

Section  of  one  lateral  half  of 
I'lG-  173.  the  spinal  cord   {Fig.  173,  a) 

causes  anaesthesia  of  the  oppo- 
site side  for  sensations  of  touch, 
pain,  temperature,  and  tickling, 
and  loss  of  the  muscular  sense 
and  motor  paralysis  on  the  same 
side. 


(6)  Functions  of  the  Central 
Orey  Column. 

§  373.  The  central  grey 
column  is  not  supposed  to  be 
endowed  with  any  active  func- 
tions, yet,  pathologically  re- 
garded, it  is,  as  will  hereafter 
appear,  one  of  the  most  im- 
portant portions  of  the  grey 
substance  of  the  spinal  cord. 
The  continuation  of  this  column 
in  the  medulla  oblongata  con- 
tains, as  we  have  seen,  the 
accessory  nuclei;  and  the  median 
areas  of  the  anterior  horn  in  the 
cervical  and  lumbar  enlarge- 
ments, as  well  as  the  medio- 
lateral  areas  in  the  dorsal  and 
upper  cervical  regions,  may  be 
regarded  respectively  as  anterior 


Fig.  173  (after  Erb).  Diagram  of  the 
Course  of  the  principal  Conducting 
Paths  within  the  Cord. — 1  and  I', 
The  motor  and  vase -motor  tracts, 
passing  through  the  anterior  root  iv), 
and  remaining  on  the  same  side  of 
the  cord ;  2  and  2',  Tracts  which 
conduct  the  muscular  sensibility,  also 
passing  through  the  anterior  roots, 
and  remaining  on  the  same  side  of 
the  cord ;  3  and  3',  The  tracts  which 
conduct  sensory  impressions  of  touch, 
temperature,  pain,  and  tickling. 
These  enter  the  cord  through  the 
posterior  roots,  and  cross  to  the  other 
side,  and  pursue  their  course  upwards 
on  that  side.  Section  of  the  right 
half  of  the  cord  (a)  must  interrupt 
conduction  through  the  motor,  vaso- 
motor, and  musculo-sensory  tracts  (I 
and  2)  on  the  right  side,  and  the 
cutaneous  sensory  tracts  on  the  left 
side  (3'). 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.        829 

and  lateral  outgrowths  of  the  central  column,  instead  of  being 
regarded  as  portions  of  the  anterior  horns.  These  areas,  indeed, 
constitute  the  border -land  between  the  central  column  and 
anterior  horn,  and  they  are  involved  in  the  diseases  of  both 
structures. 

(7)  The  Functions  of  the  Spinal  Motor  Ganglion  Cells  luhile 
acting  in  subordination  to  the  Corticcd  Centres  of  the 
Brain. 

§  374.  The  special  functions  of  the  cord  are  those  by 
which  the  spinal  centres  are  subordinated  to  the  motor 
centres  of  the  cortex  of  the  brain.  It  is  probable  that  all 
the  spinal  nuclei  are  connected  with  the  motor  centres  of 
the  cortex  of  the  brain,  or  are,  in  other  words,  under  voluntary 
control;  but  the  later-acquired  movements  of  man  are  more 
thoroughly  under  voluntary  guidance  than  the  earlier-acquired 
or  fundamental  actions.  Inasmuch  as  the  observation  of  the 
development  of  the  cord  has  enabled  us  to  draw  a  broad  dis- 
tinction between  the  fundamental  and  accessory  portions  of  the 
structure  of  the  spinal  cord,  it  will  be  well  to  endeavour  first 
to  connect  the  later-acquired  or  accessory  functions  with  the 
later-acquired  or  accessory  structures.  The  earlier-acquired  or 
fundamental  functions  will  then  be  left  as  a  residuum  to  be 
connected  with  the  fundamental  structures  of  the  cord.  We 
shall  now  proceed  to  describe  (a)  the  accessory  and  (h)  the 
fundamental  functions  of  the  spinal  cord  and  medulla  oblongata. 

(a)  The  Accessory  Functions  of  the  Spinal  Cord  and  Medulla  Oblongata. 

The  movements  of  the  hand  afford  the  best  example  of  the  accessory 
functions  of  the  spinal  cord.  These  movements  are  peculiar  to  man,  and  by 
far  the  greater  number  of  them  are  acquired  after  bii'th.  It  may,  therefore, 
be  expected  that  the  development  of  the  structure,  which  represents  these 
movements  in  the  spinal  cord,  will  also  take  place  after  birth. 

The  movements  which  are  most  characteristic  of  the  upper  extremity  in 
man  are  those  of  pronation  and  supination  of  the  forearm  and  the  compli- 
cated movements  of  the  hand  and  fingers,  and  it  is  exceedingly  probable 
that  the  structural  representatives  of  some  if  not  all  of  these  movements 
are  to  be  found  in  the  median  group  of  cells.  These  cells  appear  at  a  late 
period  of  the  development  of  the  cord,  hence  they  form  a  speciahty  of 
structure  which  corresponds  to  some  speciahty  of  function ;  again  they 


830        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

maintain  a  small  size  even  in  the  adult  cord,  and  consequently  may  be 
expected  to  preside  over  the  action  of  small  muscles,  both  of  these  conditions 
being  realised  in  the  hand. 

The  smaller  median  area  in  the  lumbar  enlargement  of  the  cord  presides 
probably  over  the  movements  of  the  lower  limbs,  which  distingmsh  the 
adult  man  from  the  lower  animals  and  also  from  the  human  infant.  These 
movements  are  mainly  executed  by  the  extensors  of  the  leg  on  the 
thigh  and  probably  also  by  the  adductors,  and  by  the  flexors  of  the  foot  on 
the  leg.  Indeed,  the  slight  elevation  of  the  ball  of  the  toe,  so  as  to  allow 
the  passive  leg  to  swing  forwards  by  its  own  weight  in  walking,  is  the  last 
movement  acquired  by  the  child  ;  and  we  shall  subsequently  see  that  it  is 
the  first  movement  to  be  affected  in  disease.  If,  then,  the  median  area  of 
small  cells  be  the  structural  con-elative  of  the  later-acquired  and  more 
special  movements  of  the  limbs,  it  must  be  absent  in  those  portions  of  the 
cord  which  do  not  supply  nerves  to  limbs,  and  we  have  already  seen  that 
this  area  is  absent  in  the  dorsal  and  upper  cervical  regions  of  the  cord. 

It  must  be  remembered  that  the  muscles  of  the  hand  are  connected  with 
the  earlier-formed  or  fundamental  cells  of  the  anterior  horns,  and  that  the 
small  cells  of  the  median  area  do  not  of  themselves  suffice  for  the  regulation 
of  their  movements.  The  increased  development  of  the  median  area  in  the 
cervical  enlargement  represents  merely  a  complication  on  the  previous 
structure  of  the  cord  corresponding  to  the  comphcation  of  muscular  adjust- 
ments which  distingmshes  the  hand  of  man  from  the  anterior  extremity  of 
animals. 

The  hypoglossal  accessory  nucleus,  and  the  internal  and  external  accessory 
facial  nuclei,  appear  to  be  the  homologues  in  the  medulla  oblongata  of  the 
median  area  in  the  cervical  and  lumbar  enlargements  of  the  spinal  cord. 
The  hypoglossal  accessory  nucleus  seems  to  be  the  additional  structural 
complication  rendered  necessary  by  the  complicated  movements  executed  in 
the  production  of  articulatory  speech ;  while  the  facial  accessory  nuclei  are 
the  structural  counterparts  in  the  medulla  of  the  movements  of  facial 
expression. 

The  next  accessory  function  which  I  shall  mention  is  the  muscular 
adjustments  necessary  for  maintaining  the  erect  posture  in  man.  These 
adjiostments  are  also  acquired  a  considerable  time  after  birth,  hence  it  may 
be  inferred  that  their  structural  counterpart  in  the  cord  is  not  well  developed 
at  birth.  The  medio-lateral  area  corresponds  in  my  opinion  to  these  adjust- 
ments in  the  dorsal  region  of  the  cord.  The  cells  of  this  area  are  not  welj 
developed  at  birth,  and  the  area  is  entirely  absent  in  the  lower  animals. 
These  cells  are  also  of  small  size,  even  in  the  adult  cord,  and  if,  as  we  have 
already  stated,  the  size  of  the  ganglion  cell  is  related  to  the  size  of  the 
muscle  with  which  it  is  connected,  the  erectores  spinse  are  the  muscles  of 
the  trunk  which  best  correspond  to  this  description.  The  medio-lateral 
area  appears  also  in  the  upper  cervical  region,  and  it  may  be  presumed  that 
the  small  muscles  which  extend  the  vertebral  column  in  the  neck,  and  draw 
back  and  rotate  the  head,  are  supplied  from  these  cells.     We  have  already 


ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION.        831 

seen  that  some  of  the  fibres  of  the  eleventh  nerve  (spinal  accessory)  are 
derived  from  the  postero-lateral  group  in  the  cord,  and  it  is  very  probable 
that  the  accessory  nucleus  of  this  nerve  in  the  medulla  is  the  homologue  of 
the  medio-lateral  area  in  the  upper  cervical  and  dorsal  regions  of  the  cord. 
The  accessory  nucleus  of  the  eleventh  nerve  is  the  additional  organisation 
rendered  necessary  by  the  complicated  movements  of  the  human  larynx. 

The  marginal  cells  of  the  postero-lateral,  antero-lateral,  and  central 
groups  appear  late  in  the  development  of  the  cord,  and  these  therefore  must 
be  regarded  as  belonging  to  the  accessory  system,  even  although  the  ganglion 
cells  are  of  comparatively  large  size.  The  fact  that  these  cells  are  of  large 
size  shows  that  they  must  be  engaged  in  the  regulation  of  the  movements 
of  large  muscles.  It  is  probable  that  these  marginal  cells  in  the  lumbar 
region  regulate  the  contractions  of  the  large  muscles  of  the  lower  extremity 
which  are  engaged  in  maintaining  the  erect  posture.  The  great  relative 
size  of  the  gluteus  maximus  in  man,  as  compared  with  the  lower  animals, 
would  appear  to  render  necessary  a  corresponding  increase  in  the  number 
of  ganglion  cells  of  the  spinal  nucleus  which  regulates  its  movements  in 
the  former,  as  compared  with  that  in  the  latter.  And  inasmuch  as  the 
gluteus  maximus  is  not  much  called  into  action  until  a  considerable  time 
after  birth,  these  superadded  cells  must  belong  to  the  accessory  system. 
These  additional  cells  may  probably  be  represented  by  the  marginal  cells  of 
the  postero-lateral  group  in  the  lumbar  region.  The  alternate  upward 
rotation  of  the  pelvis,  which  takes  place  in  walking,  and  which  is  mainly 
eflfected  by  contraction  of  the  gluteus  medius  and  minimus,  is  likewise  a 
very  special  movement ;  and  it  also  must  be  regulated  by  the  later-developed 
cells  of  one  or  other  of  these  groups  of  ganglion  cells  in  the  anterior  horns. 

We  have  seen  that  the  postero-lateral  group  in  the  upper  cervical  region 
gives  off  the  spinal  portion  of  the  spinal  accessory  nerve,  and  that  this  portion 
forms  the  external  branch  of  the  nerve,  which  is  distributed  to  the  sterno- 
cleido-mastoid  muscle  and  the  upper  portion  of  the  trapezius.  But  in  man 
the  sterno-cleido-mastoid  is  in  close  relation  with  the  clavicular  portion  of 
the  pectoralis  major,  being  only  separated  from  it  by  the  clavicle,  and  in 
those  animals  in  which  the  clavicle  is  deficient  it  runs  with  the  anterior 
part  of  the  trapezius  muscle  into  the  deltoid,  forming  a  mastoido-humeral 
muscle.  All  of  these  muscles  are  closely  associated  in  their  actions,  and  it 
is,  therefore,  probable  that  all  are  innervated  from  the  postero-lateral 
group,  while  the  latissimus  dorsi,  rhomboidei,  and  several  other  muscles 
may  perhaps  be  added  to  this  list.  It  is  very  probable  indeed  that  the 
muscles  which  may  be  compendiously  summed  up  with  reference  to  their 
fvmctions  as  the  accessory  muscles  of  inspiration  are  innervated  from  this 
group  in  the  cervical  and  dorsal  regions.  These  muscles  are  briefly  the 
sterno-mastoids  and  scaleni,  the  pectoralis  major  and  minor,  the  serrati 
postici  et  superiores,  the  subclavius,  and  the  extensors  of  the  head  and 
spinal  column. 

The  postero-lateral  and  medio-lateral  groups  of  ganglion  cells  consist  of 
a  series  of  superimposed  ganglionic  centres,  constituting  a  column  of  cells 


832        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

wliicli  extends  from  the  liunbar  region,  tkrough  the  dorsal  and  cervical 
regions  of  the  cord  to  the  medulla  and  pons.  Speaking  broadly,  this 
colunm  regulates  the  muscular  contractions  necessary  for  the  maintenance 
of  the  erect  postm-e,  the  contraction  of  the  extraneous  muscles  of  respira- 
tion, in  part  at  least  that  of  the  muscles  supphed  by  the  spinal  accessory, 
vagus,  glosso-pharyngeal,  seventh,  and  by  the  motor  branch  of  the  fifth 
nerves.  The  portion  of  the  facial  nerve  supplied  by  the  continuation  of 
the  postero-lateral  group  in  the  medulla  probably  presides  over  the  function 
of  the  facial  muscles  in  their  relation  with  mastication  and  respiration. 
The  series  of  superimposed  ganglionic  centres  of  which  the  postero-lateral 
group  consists  cannot  act  independently  of  each  other  ;  and  in  order  to 
secure  harmony  of  action,  some  of  these  centres  must  become  subordinate 
to  other  centres,  either  of  the  same  column  or  of  some  other  part  of  the 
nervous  system.  All  of  them  are  doubtless  co-ordinated  in  the  cortex  of 
the  brain,  but  it  is  not  improbable  that  the  inferior  centres  of  the  column 
are  also  subordinated  to  one  of  the  superior  centres  in  the  medulla 
oblongata.  If  such  should  be  the  case,  there  is  no  occasion  for  assuming 
the  existence  of  a  distinct  respiratory  centre  in  the  medulla  oblongata 
apart  from  the  upward  continuation  of  the  postero-lateral  colmnn  of  cells. 
It  is  much  more  probable  that  the  respiratory  centre  is  merely  an  enlarge- 
ment in  the  meduUa  of  the  postero-lateral  column  of  cells.  It  is  also  quite 
likely  that  this  enlargement  is  closely  connected  with  the  other  groups  of 
cells  which  have  been  continued  upwards  from  the  cord  into  the  medulla. 

(b)  Fundamental  Voluntary  Functions, 

With  respect  to  the  functions  of  the  antero-lateral  group,  I  must 
content  myself  by  saying  very  little.  The  cells  of  this  group  always 
maintain  the  lead  in  the  course  of  development.  It  is  not  only  that 
they  begin  to  develop  and  assume  processes  at  an  earlier  period  than 
the  cells  of  the  other  groups,  but  the  greater  portion,  if  not  all  of  them, 
appear  almost  simultaneously,  and  maintain  an  equal  rate  of  growth 
during  development.  The  antero-lateral  differs  in  this  respect  from 
the  postero-lateral  and  central  groups,  which  increase  in  size  by  the 
gradual  addition  of  new  ganglion  cells  at  their  margins.  It  may  be 
expected,  therefore,  that  this  group  will  regulate  the  fundamental  actions, 
or  the  actions  which  are  carried  on  in  a  reflex  manner,  and  which  are  in 
great  measure  independent  of  the  cephahc  ganglia.  In  this  connection  the 
intercostal  muscles,  the  diaphragm,  abdominal  muscles,  and  the  muscles 
constituting  the  floor  of  the  pelvis  will  immediately  suggest  themselves. 
In  the  lower  extremity  the  most  general  movements  may  be  expected  to  be 
regulated  by  the  antero-lateral  group.  These  movements  are  flexion  of  the 
thigh  on  the  body,  of  the  leg  on  the  thigh,  and  elevation  of  the  heel.  It 
may  be  said  that  elevation  of  the  heel  is  a  movement  almost  pecuhar  to 
man,  and  that  it  is  consequently  a  very  special  movement.  But  in  animals 
he  heel  is  permanently  elevated,  and  in  man  it  requires  to  be  raised  at 


ANATOMICAL   AND  PBTSIOLOGICAL   INTRODUCTION.        833 

each  step  because  of  the  depression  of  it  which  has  been  effected  in  the 
course  of  evolution,  by  the  progressive  increase  in  the  strength  of  the 
flexors  of  the  foot  on  the  leg. 

On  watching  the  first  movements  of  the  human  infant  it  will  be  seen 
that  the  power  to  elevate  the  heel  is  acquired  early,  while  the  elevation  of 
the  toe  so  as  to  allow  the  foot  to  swing  forwards  by  its  own  weight  is  the 
last  movement  acquired ;  hence  the  latter  is  the  most  special  movement, 
which  must  be  represented  in  the  cord  by  the  superaddition  of  new  ganghon 
cells  to  those  already  existing.  What  the  movements  are  which  are  regulated 
by  means  of  the  antero-lateral  group  in  the  cervical  region  I  can  only  make 
a  rough  conjecture.  They  are  no  doubt  the  simplest  movements,  and 
those  which  man  possesses  in  common  with  the  lower  animals.  The  most 
probable  of  these  movements  are  flexion  at  the  wrist,  simple  flexion  and 
extension  at  the  elbow,  and  the  backwards  and  forwards  movements  at 
the  shoulder,  and  flexion  of  the  neck  and  head.  Some  of  the  muscles 
engaged  in  these  actions  we  have  already  found  reason  to  believe  were 
innervated  from  the  postero-lateral  group ;  but  this  does  not  exclude  the 
possibihty  of  their  being  innervated  also  from  the  antero-lateral  group. 
There  is  so  much  uncertainty,  however,  with  regard  to  the  fimction  of  the 
antero-lateral  gi-oup  in  the  cervical  region  that  it  would  be  hazardous  to 
make  any  assertion  with  regard  to  it.  There  is  also  quite  as  much  uncer- 
tainty with  respect  to  the  functions  of  the  central,  internal,  and  anterior 
groups. 

(8)  Functions  of  the  Special  Nuclei  of  the  Medulla  Oblongata, 
Pon^,  and  Crura. 

§  375.  The  functions  of  the  special  nuclei  do  not  require 
extended  consideration  at  present.  All  of  them  serve  to 
transmit  impulses  received  through  the  nerves  of  special  sense, 
not  only  to  the  cortex  of  the  brain,  but  probably  also  to  the 
cortex  of  the  cerebellum,  while  likewise  ministering  to  complex 
reflex  actions.  Two  of  the  four  nuclei  of  origin  of  the  auditory 
nerve  are  intimately  connected  with  the  inferior  and  middle 
peduncles  of  the  cerebellum,  and  it  is  probable  that  one  of  them 
at  least  conducts  labyrinthine  impressions  to  the  cerebellum. 
The  corpora  quadrigemina,  again,  are  anatomically  connected, 
not  only  with  the  cerebrum,  but  also  with  the  superior  peduncles 
of  the  cerebellum ;  while  they  have  been  proved,  both  anatomi- 
cally and  experimentally,  to  form  an  important  reflex  centre 
between  the  retina  and  the  internal  and  external  muscles  of  the 
eye.  It  is,  indeed,  likely  that  still  more  extensive  and  complex 
reflex  actions  are  regulated  by  the  corpora  quadrigemina,  since 

VOL.  L  BBB 


834        ANATOMICAL   AND  PHYSIOLOGICAL  INTRODUCTION. 

they  are  known  to  be  anatomically  connected  with  the  upward 
continuation  of  the  anterior  root-zones  of  the  spinal  cord. 

The  corpora  quadrigemina  are  homologous  with  the  optic  lobes  in  fishes 
and  the  lower  vertebrata — organs  which  are  developed  in  connection  with 
the  sense  of  sight.  These  ganglia  appear  to  be  the  centres  for  the  reflex 
co-ordination  of  all  the  muscular  actions  concerned  in  the  movements  of 
the  eyeballs  and  of  the  reflex  contraction  of  the  pupils  caused  by  light 
falling  on  the  retinae.  It  is  through  these  bodies,  and  not  directly,  that 
the  optic  tracts  come  into  relation  with  the  cerebellum  ;  hence  it  may  be 
expected  that  they  will  be  associated  with  the  latter  in  its  fimctions.  We 
have  already  seen  that  the  corpora  quadrigemina  are  connected  with  the 
anterior  root-zones,  or  the  system  of  fibres  which  co-ordinate  the  actions 
of  the  cord  longitudinally  on  the  side  of  the  outgoing  currents  ;  hence  the 
inferior  segments  of  the  body  are  to  a  considerable  extent  brought  under 
the  regulative  influence  of  these  ganglia.  The  corpora  quadrigemina  are, 
however,  simple  co-ordinating  centres,  and  their  regulative  action  on  the 
inferior  segments  of  the  body  is  of  a  purely  reflex  character.  The  following 
may  be  taken  as  an  illustration  of  the  manner  in  which  I  believe  them  to 
act  : — While  a  fish  is  swimming  through  the  water  a  sudden  impression  is 
made  on  the  right  eye  by  the  shadow  of  a  large  approaching  object,  and 
immediately  the  muscles  of  the  tail  on  the  left  side  contract,  and  the  head 
is  turned  away  from  the  object.  Such  a  movement  would  tend  to  secure 
the  safety  of  the  fish  from  capture  by  a  more  powerful  antagonist.  If,  on 
the  other  hand,  the  impression  is  made  by  a  relatively  small  object,  the 
muscles  of  the  tail  on  the  same  side  might  contract,  so  as  to  turn  the  head 
towards  the  object — a  movement  which  would  tend  to  secure  prey.  In 
these  movements  the  main  regulative  centres  are  the  optic  lobes,  and  there 
is  no  occasion  to  believe  that  the  actions  are  in  any  way  of  a  difierent 
character  from  the  ordinary  reflex  movements  of  the  spinal  cord.  It  may, 
however,  be  remarked,  in  passing,  that  since  a  large  approaching  object 
would  produce  a  greater  impression  than  a  small  object,  a  rudimentary  eye 
would  be  more  useful  to  its  possessor  for  avoiding  caj)ture  than  in  securing 
prey ;  and,  consequently,  the  primary  and  fundamental  connection  between 
the  eye  and  the  inferior  segments  of  the  body  would  be  a  crossed  one.  The 
most  ready  communication,  therefore,  would  be  between  the  right  eye  and 
the  muscles  of  the  left  side  of  the  body.  And  this  helps  to  explain  the 
crossing  of  the  optic  nerves,  not  only  in  the  lower  animals  with  rudimentary 
eyes,  but  in  the  higher  organisms ;  since,  during  the  development  of  the 
latter  from  the  former,  the  primary  and  fundamental  crossing,  however 
much  it  may  be  modified,  is  still  retained.  It  is,  indeed,  very  probable 
that  the  crossed  connection  which  may  be  supposed  to  exist  in  the  lower 
vertebrata  between  the  rudimentary  eyes  and  the  muscles  of  the  body  was 
the  main  factor  in  determining  during  the  course  of  development  the 
crossed  connection  which  exists  between  the  cerebral  hemispheres  and  the 
spinal  cord  in  the  higher  vertebrata. 


ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION.        83o 
(II.)  FUNCTIONS  OF  THE  WHITE  SUBSTANCE  OF  THE  SPINAL  AXIS. 

§  376.  According  to  the  fundamental  law  of  development 
already  mentioned,  we  may  expect  that  the  parts  of  the  cord 
which  begin  to  develop  at  an  early  period  are  engaged  in  the 
most  general  actions  ;  while  those  which  develop  at  a  late  period 
are  engaged  in  the  most  special  actions.  The  most  general 
actions  of  the  cord  are  those  which  it  performs  as  a  group  of 
simple  co-ordinating  centres ;  and  the  most  special  are  those 
which  it  performs  in  subordination  to  the  compound  and  doubly 
compound  co-ordinating  centres.  We  may,  therefore,  expect  to 
find  that  the  anterior  and  posterior  root-zones,  which  appear  at 
a  comparatively  early  period  in  the  development  of  the  cord, 
belong  to  the  spinal  system  of  simple  co-ordinating  centres, 
while  the  direct  cerebellar  fibres,  the  column  of  GoU,  and  the 
pyramidal  tract,  which  appear  at  a  comparatively  late  period  of 
development,  bring  the  simple  co-ordinating  centres  of  the  cord 
under  the  control  and  guidance  of  the  compound  and  doubly 
compound  co-ordinating  encephalic  centres.  So  far  as  can  be 
ascertained,  this  expectation  is  realised. 

(1)  Functions  of  the  Anterior  and  Posterior  Root-zones. 

§  377.  These  consist,  as  already  stated,  of  looped  fibres,  which 
connect  ganglion  cells  at  different  elevations  in  the  cord.  The 
anterior  root-zone  maintains  a  close  relationship  with  the  anterior 
grey  horns,  and  its  fibres  probably  assist  in  co-ordinating  efferent 
impulses  from  above  downwards.  But  although  the  anterior 
root-zone  belongs  primarily  to  the  spinal  system,  it  is  not  im- 
probable that  it  may  have  become  at  a  subsequent  stage  of 
development  connected  indirectly,  if  not  directly,  with  some 
of  the  cephalic  centres.  The  close  relationship  of  the  olivary 
body  with  the  anterior  root-zone  in  the  medulla  would  seem 
to  imply  that  the  latter  may  be  the  medium  of  conveying 
efferent  impulses  from  the  cerebellum.  The  anterior  root-zone 
is  also  probably  connected  with  the  corpus  striatum,  and  may 
therefore  be  the  channel  through  which  the  efferent  impulses 
from  the  latter  are  conveyed  downwards  to  the  cord.  It  is  also 
connected  with  the  corpora  quadrigemina,  and  may  serve  to 
convey  reflex  impulses  originating  in  the  retina  down  the  cord. 


836        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

The  posterior  root-zone,  on  the  other  hand,  maintains  an  equally 
close  relationship  with  the  posterior  grey  horns,  and  its  fibres 
probably  assist  in  co-ordinating  afferent  impulses  from  below 
upwards.  We  have  seen  that,  with  the  exception  of  the  part 
which  belongs  to  the  sensory  roots  of  the  fifth  nerve  and  the 
fasciculus  rotundus,  the  posterior  root-zone  terminates  in  the 
triangular  nucleus,  and  that  the  latter  is  connected  by  arcuate 
fibres  with  the  olivary  body,  which  in  its  turn  is  connected 
with  the  opposite  half  of  the  cerebellum.  This  indirect  con- 
nection with  the  cerebellum  would  appear  to  indicate  that 
some  at  least  of  the  fibres  of  the  posterior  root-zone  belong  to 
the  cerebello-spinal  system. 

(2)  Functions  of  the  Direct  Cerebellar  Tract. 

§  378.  This  tract  belongs  to  the  cerebello-spinal  system,  its 
fibres  connecting  the  vesicular  column  of  Clarke  and  the  cortex 
of  the  cerebellum  (Flechsig).  Little  is  known  with  regard  to 
the  functions  of  these  fibres,  except  that  they  appear  to  convey 
afferent  impulses.  This  is  presumed  to  be  the  case,  because 
when  the  fibres  of  the  tract  are  injured  in  any  part  of  their 
course,  the  portions  above  the  seat  of  injury  undergo  rapid 
degeneration. 

(3)  Functions  of  the  Column  of  Goll. 

§  379.  This  column  must  be  regarded  as  a  special  structure 
from  the  comparatively  late  period  at  which  it  is  developed. 
Its  fibres  also  undergo  rapid  degeneration  above  the  seat  of 
injury ;  hence  it  may  be  inferred  that  they  convey  afferent 
impulses,  bat  nothing  further  is  known  with  regard  to  their 
functions. 

(4)  Functions  of  the  Pyramidal  Tract. 

§  380.  This  tract  is  now  well  known  to  be  the  means  of  com- 
munication between  the  motor  area  of  the  brain  and  the  anterior 
grey  horns  of  the  cord ;  it  also  contains  the  vaso-motor  centri- 
fugal conducting  tracts,  and  the  paths  for  muscular  sense,  but 
whether  the  latter  are  represented  by  distinct  fibres  apart  from 
the  motor  fibres  is  doubtful. 


ANATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION.        837 

The  fibres  which  pass  ioto  the  lateral  column  connect  the 
anterior  grey  horn  of  one  side  with  the  cortex  of  the  opposite 
side ;  while  those  which  constitute  the  column  of  Tiirck  connect 
the  anterior  horns  and  cortex  on  the  same  side.  When  the 
fibres  of  the  tract  are  injured  in  any  part  of  their  course  the 
portions  below  the  seat  of  injury  undergo  rapid  degeneration, 
and  this  fact  alone  is  sufficient  to  indicate  that  these  fibres 
convey  efferent  impulses.  This  tract  is,  indeed,  the  channel  by 
means  of  which  voluntary  impulses  are  conveyed  from  the  cortex 
of  the  brain  to  the  spinal  cord.  The  crossed  and  direct  connec- 
tion which  this  tract  forms  between  the  cortex  of  the  brain  and 
the  grey  anterior  horns,  is  rendered  necessary  by  the  fact  that 
every  movement  of  one  side  of  the  body  alters  the  centre  of 
gravity,  and  necessitates  a  new  adjustment  of  the  opposite  side. 
I  obtained  this  idea  in  a  conversation  with  Dr.  Hughlings 
Jackson,  and  he  illustrated  his  meaning  by  showing  that  when 
a  man  stands  on  the  ball  of  the  right  foot,  and  stretches  his 
right  arm  upwards  and  forwards  to  reach  an  object,  the  body 
being  also  inclined  forwards,  the  left  leg  is  instinctively  thrust 
backwards,  and  the  left  arm  downwards  and  backwards,  in  order 
to  keep  the  centre  of  gravity  as  far  back  as  possible  and  so  to 
prevent  the  line  of  gravity  from  passing  in  front  of  the  ball  of 
the  right  foot.  The  muscular  contractions  of  the  right  side  of  the 
body  may  be  supposed  to  be  regulated  in  this  action  from  the  left 
cortex  of  the  brain  through  the  fibres  of  the  pyramidal  tract  of 
the  lateral  column  of  the  right  side,  while  the  movements  of  the 
left  arm  and  leg  are  also  regulated  from  the  left  cortex,  but  the 
impulses  are  conveyed  to  the  same  side  of  the  cord  and  of  the  body 
by  the  fibres  of  the  column  of  Tiirck. 


(B)  Functions  of  the  Superadded  Grey  Substance  of  the  Medulla 
Oblongata,  Pons,  and  Crura. 

§  381.  We  have  already  seen  that  there  are  no  grounds  for 
believing  that  the  centres  of  respiration,  deglutition,  mastication, 
and  the  regulation  of  the  heart's  action,  the  vaso-motor  diabetic, 
and  so-called  convulsive  centre  of  Nothnagel,  are  represented  by 
grey  matter  in  the  medulla,  apart  from  that  which  is  the  upward 
continuation  of  the  grey  substance  of  the  spinal  cord,  and  con- 


838        ANATOMICAL  AND  PHYSIOLOGICAL  INTRODUCTION. 

sequently  the  masses  of  grey  matter  which  are  superadded  in  the 
medulla,  pons,  and  crura,  must  preside  over  other  important 
functions.  Little,  however,  is  known  with  respect  to  these.  The 
most  reasonable  supposition  I  can  form  is  that  all  of  them  are 
connected  with  the  cerebello-spinal  system,  and  are,  therefore, 
engaged  in  regulating  the  tonic  muscular  contractions  rendered 
necessary  to  maintain  the  various  attitudes  of  the  body. 


839 


CHAPTER   11. 


MORBID  ANATOMY  AND  CLASSIFICATION  OF  THE  DISEASES 
OF  THE   SPINAL  CORD  AND  MEDULLA  OBLONGATA. 

L— MORBID   ANATOMY   OF    THE    SPINAL    CORD    AND 
MEDULLA   OBLONGATA. 

In  the  preceding  chapter  we  have  traced  the  operation  of  the 
law  of  evolution  in  the  development  of  the  spinal  cord  and 
medulla  oblongata ;  we  must  now  trace  the  operation  of  the  law 
of  dissolution  in  the  breaking  down  of  the  structure  of  these 
organs  by  disease.  In  passing  under  brief  review  the  morbid 
alterations  of  the  spinal  cord  and  medulla  oblongata,  we  shall 
describe — (A)  the  histological  changes  of  the  various  elements  of 
these  organs ;  (B)  the  secondary  degenerations  of  the  embryo- 
logical  systems;  and  (C)  the  deformities  and  malformations  of 
the  cord  and  medulla;  while  we  shall  endeavour  to  show  (D) 
how  all  these  changes  illustrate  the  law  of  dissolution. 

(A)  Histological  Changes. 

§  382.  The  histological  morbid  changes  may  be  divided  into 
those  which  occur  in  (i.)  the  ganglion  cells,  (il.)  the  nerve  fibres, 
(ill.)  the  neuroglia  and  connective  tissue,  and  (iv.)  the  blood- 
vessels. 

(L)   MORBID  CHANGES  OP  THE  GANGLION  CELLS. 

(1)  Hypertrophy. — In  acute  inflammation  of  the  cord  tlie  ganglion  cells 
become  swollen,  their  contents  are  cloudy  and  granular,,  and  their  processes 
also  participate  in  the  changes  {Fig.  174,  2).  These  cells  often  contain  a 
large  amount  of  yellow  pigment,  a  condition  which  has  been  described  by 
Dr.  AUbutt  as  "  yellow  degeneration  "  {Fig.  174,  3). 

(2)  Shrinking. — In  the  acute  diseases  of  the  grey  substance  of  the  cord, 


840 


MORBID  ANATOMY  OF  THE 


the  ganglion  cells,  especially  the  small  cells  of  the  median  areas,  become 
shrivelled ;  their  fluid  contents  appear  to  have  escaped,  and  the  cell  wall  to 
have  shrunk  around  the  nucleus  and  a  small  quantity  of  yellow  pigment 
(Fig.  174,  4).  At  a  subsequent  period  the  cells  lose  their  processes  and 
become  converted  into  small  angular  masses,  in  which  even  a  nucleus 
cannot  be  detected. 

(3)  Multiplication  of  the  Nucleus  and  Nucleolus. — The  nucleus  and 
nucleolus  may  at  times  be  observed  either  to  have  divided  into  two,  or  to 
eshibit  an  hoxir-glass  contraction  indicating  that  the  process  of  division  has 
commenced. 

(4)  Vacuolation. — Two  or  three  large  spherical  air  spaces,  named 
vacuoles,  may  sometimes  be  observed  in  ganglion  cells  which  have  undergone 
a  granular  degeneration  (Fig.  174,  7). 

(5)  Colloid  Degeneration. — The  hypertrophied  cells  of  the  early  stage 

Fig.  174. 


Fig,  174  (Young).  Ganglion  Cells  of  the  Anterior  Grey  Horns  of  the  Spinal  Cord, — 
1,  Healthy  caudate  cell ;  2,  Hypertrophied  cell ;  3,  Yellow  degeneration  (the 
yellow  colour  cannot  be  represented  here) ;  4,  Shrivelled  cell ;  5,  Chronic 
atrophy,  a  group  of  cells  from  a  case  of  pseudo-hypertrophic  paralysis  ;  6,  Pig- 
mentary atrophy ;  7,  Vacuolation,  from  a  case  of  canine  chorea  (Gowers) ; 
8.  Chronic  atrophy,  from  a  case  of  progressive  muscular  atrophy — "yellow 
atrophy." 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  841 

of  inflammation  may  subsequently  undergo  colloid  degeneration.  Their 
processes  become  transparent,  glistening,  brittle,  and  a  large  number  of 
them  are  broken  oflf  so  that  the  cells  assume  a  rounded  form.  The  cell 
wall  has  a  glassy  appearance,  and  assumes  brilliant  tints  when  stained  by 
various  aniline  dyes.  The  colloid  appearances  may  probably  be  the  restxlt 
of  post-mortem  changes,  and  consequently  considerable  caution  must  be 
exercised  in  accepting  them  as  evidences  of  disease. 

(6)  Pigmentary  Degeneration. — The  best  examples  of  pigmentary  de- 
generation are  seen  in  the  chronic  diseases  of  the  cord.^  The  cell  wall 
becomes  contracted  around  a  mass  of  dark  granular  pigment,  the  nucleus 
and  nucleolus  are  indistinct  or  obliterated,  the  processes  are  atrophied,  and 
many  of  them  have  disappeared  {Fig.  174,  6). 

(7)  Atrophy. — In  chronic  diseases  the  cell  wall  becomes  dense  and  con- 
tracted, the  processes  are  broken  off,  and  the  remnant  of  the  cell  is  con- 
verted into  a  small  angular  mass,  without  recognisable  nucleus  or  nucleolus, 
and  finally  all  traces  of  the  cell  may  be  lost  {Fig.  174,  5  and  8). 

(8)  Calcareous  degeneration  of  the  ganglion  cells  of  the  cord  is  rarely 
observed  (Forster). 

(II.)  MORBID  CHANGES  OP  THE  NERVE  FIBRES. 

The  meduUated  nerve  fibres  of  the  spinal  cord  undergo  alterations 
more  or  less  similar  to  those  which  have  already  been  described  in  the  case 
of  the  fibres  of  the  peripheral  nerves,  and  consequently  these  changes  need 
not  be  described  here  in  detail. 

(1)  Hypertrophy  of  the  Axis  Cylinder. — In  myelitis  it  is  not  rare  to 
observe  on  transverse  section  that  the  axis  cylinders  of  many  of  the  fibres 
have  increased  to  two  or  three  times  their  normal  dimension.  In  longitu- 
dinal sections  it  is  seen  that  the  swelling  does  not  extend  the  whole  length 
of  the  axis  cylinder  ;  the  latter  presents  a  varicose  appearance,  so  that  its 
diameter  is  much  diminished  in  size  at  some  points. 

(2)  Atrophy  of  the  nerve  fibres,  similar  to  that  which  occurs  in  the  peri- 
pheral nerves  when  the  fibres  are  severed  from  their  trophic  centres,  may 
be  observed  in  the  meduUated  fibres  of  the  spinal  cord.  This  atrophy 
begins  by  coagulation  of  the  myeline,  which  becomes  granular  and  broken 
up  into  globular  masses  that  are  finally  absorbed.  The  axis  cylinder 
persists  for  a  long  time  after  the  medullary  sheath  has  disappeared,  but 
by-and-by  it  also  diminishes  in  size,  and  ultimately  disappears. 

(3)  Calcareous  degeneration  of  the  fibres  of  the  cord  has  been  excep- 
tionally observed  (Forster,  Virchow). 

(III.)  MORBID  CHANGES  OF  THE  NEUROGLIA  AND  CONNECTIVE  TISSUE. 

(1)  GlUge's  corpuscles  consist  of  large  globular  cells  filled  with  granidar 
contents.     These  cells  may  be  observed  in  the  spinal  cord  of  the  embryo, 

1  See  Charcot.  Lecons  sur  les  maladies  du  systeme  nerveux.  Tome  II.,  2«  Edit., 
1877,  p.  184. 


842  MORBID  ANATOMY  OF   THE 

but  are  never  met  with,  in  considerable  numbers  in  the  cord  of  the  adult, 
except  in  cases  of  disease.  They  are  supposed  to  derive  their  origin  from 
fatty  degeneration  of  the  cells  of  the  connective  tissue  and  neuroglia,  the 
white  corpuscles  of  the  blood,  and  the  endothehal  cells  of  the  vessels  and 
of  the  capsules  of  the  ganghon  cells. 

(2)  Amyloid  Corpuscles  and  Colloid  Bodies. — Amyloid  corpuscles  (cor- 
pora amylacea)  are  small,  round,  concentrically  laminated  bodies.  Most  of 
them  are  turned  blue,  or  bluish  grey,  when  acted  on  by  iodine  alone,  and 
assume  a  beautiful  bright  blue  tint  on  the  addition  of  sulphuric  acid. 
Colloid  boches  are  in'egular  masses,  consisting  apparently  of  changed 
myeline  ;  they  assume  beautiful  tints  on  being  stained  with  logwood,  or 
some  of  the  aniUne  dyes.  It  is  probable  that  these  bodies  may  be  the 
result  of  post-mortem  decomposition,  and  neither  they  nor  the  amyloid 
corpuscles  afford  tnistworthy  evidences  of  disease. 

(3)  Deite'r's  cells  appear  to  be  increased  in  number  in  inflammatory 
diseases  of  the  cord. 

(4)  Hypertrophy  and  Hyperplasia  of  the  Connective  Tissue. — The  septa 
of  connective  tissue  become  swollen,  and  the  nuclei  of  the  neuroglia 
largely  increased  in  number.  It  is  also  probable  that  leucocytes,  which 
have  migrated  from  the  vessels  during  inflammatory  processes,  may  sub- 
sequently become  organised,  and  thus  increase  the  normal  volume  of  the 
connective  tissue  of  the  cord. 

(5)  Sclerosis  and  Retraction. — ^Vhen  h^^perplasia  of  the  connective 
tissues  has  once  taken  place,  the  newly-form.ed  tissue  may  subsequently 
imdergo  cicatricial  contraction,  and  thus  lead  to  the  destruction  of  the 
nervous  elements.  The  process  which  leads  to  sclerosis  often  begins  in 
the  nerve  cells  and  fibres,  and  may  be  called  paretichymatous  sclerosis.  At 
other  times  the  morbid  changes  appear  to  begin  in  the  connective  tissue 
or  neuroglia,  the  nerve  cells  and  fibres  being  secondarily  invaded  ;  this 
form  may  be  called  interstitial  sclerosis. 

(IV.)  MORBID   ALTERATIONS  OF  THE  VESSELS. 

(1)  Intravascular  Changes. — The  vessels  are  at  times  greatly  distended 
with  blood,  but  this  is  not  a  trustworthy  evidence  of  disease,  inasmuch 
as  the  distension  may  have  occurred  from  the  mode  of  dying,  or  from 
hj^Dostatic  congestion  after  death.  The  capillary  arteries  may  at  times 
be  distended  with  emboli. 

(2)  Changes  in  the  walls  of  the  spinal  vessels  are  observed  in  chronic 
Bright's  disease,  identical  with  those  which  occur  in  the  vessels  of  the 
body  generally  in  that  disease. 

(3)  Perivascular  Changes. — The  most  important  perivascular  changes 
observed  in  disease  of  the  sj^inal  cord  are  caused  by  migration  of  the 
white  coi-puscles  of  the  blood  into  the  perivascular  lymph-spaces  and 
surrounding  tissues.  The  number  of  leucocytes  surrounding  a  vessel  may 
sometimes  be  so  great  as  to  constitute  what  has  been  called  a  miliary 
abscess  (Plate  V,,  Fig,  2),    Rupture  of  a  vessel  may  occur,  giving  rise  to 


SPINAL  CORD  AND  MEDULLA   OBLONGATA.  84)3 

hsemorrhage  into  the  tissues.  Eed  blood  corpuscles  are  at  times  localised 
in  a  perivascular  space,  but  it  is  difficult  to  determine  in  these  cases 
"whether  the  red  corpuscles  have  escaped  by  rupture,  or  have,  like  the  white 
corpuscles,  migrated  through  the  wall  of  the  vessel. 


(B)  Secondary  Degenerations  of  the   Embrtological   Systems  op 
THE  White  Substance. 

§  383.  The  medullated  fibres  of  the  spinal  cord  undergo  de- 
generation whenever  their  continuity  is  interrupted.  The  short 
looped  fibres  of  the  anterior  and  posterior  root-zones,  however,  only 
degenerate  in  the  neighbourhood  of  the  lesion,  probably  because 
they  soon  terminate  in  grey  matter.  But  the  fibres  which  pass 
from  one  end  of  the  cord  to  another  are  sometimes  found  degene- 
rated throughout  their  whole  length.  As  a  rule,  however,  a 
focal  lesion  interrupts  the  continuity  of  the  long  fibres  in  some 
part  of  their  course,  and  the  fibres  either  above  or  below  the 
seat  of  disease  undergo  degeneration.  Some  pathologists  think 
that  an  irritative  change  spreads  from  the  primary  lesion  as  a 
centre  along  these  fibres,  but  the  most  reasonable  supposition  is 
that  the  degeneration  is  analogous  to  what  occurs  in  the  fibres 
of  peripheral  nerves  after  they  have  been  severed  from  their 
trophic  centres.  The  trophic  centres  of  the  fibres  of  the  columns 
of  GoU  and  of  the  direct  cerebellar  tract  are  situated  at  their 
inferior  extremities — the  posterior  horn  containing  the  trophic 
centres  of  the  former,  and  the  vesicular  column  of  Clarke 
possibly  that  of  the  latter.  When,  therefore,  the  continuity  of 
these  fibres  is  interrupted  at  any  point,  the  portions  above  the 
seat  of  the  lesion  undergo  degeneration,  consequently  degene- 
ration of  these  fibres  is  called  ascending  sclerosis.  But  the 
trophic  centres  of  the  fibres  of  the  pyramidal  tract  are  situated 
at  their  superior  extremities,  these  centres  being  probably 
formed  by  the  large  ganglion  cells  of  the  fourth  layer  of  the 
cortex  of  the  brain.  When  the  continuity  of  these  fibres  is  inter- 
rupted at  any  point  of  their  course,  the  portions  below  the  seat 
of  the  lesion  undergo  degeneration,  consequently  this  form  is 
called  descending  sclerosis.  The  time  occupied  by  the  degene- 
ration appears  to  be  from  four  to  eight  weeks.  Schiefferdecker 
found  in  experiments  on  dogs  that  it  began  at  the  end  of  fourteen 
days,  and  was  well  marked  at  the  end  of  four  to  five  weeks,  but 


814  MORBID  ANATOMY  OF  THE 

changes  in  the  connective  tissue  were  not  observed  until  the 
eighth  week.  Degeneration  of  the  fibres  of  the  spinal  cord 
appears  always  to  take  place  in  the  line  of  their  conduction. 
When  a  transverse  section  of  the  spinal  cord  is  examined  by  the 
naked  eye  the  degenerated  portion  usually  presents  a  grey  or 
greyish  discolouration,  but  in  recent  cases  the  cord  presents  no 
abnormal  appearances  until  it  is  hardened  in  chronic  acid  or 
bichromate  of  ammonia.  In  cases  of  long  standing  the  degene- 
rated columns  may  be  atrophied  to  such  an  extent  that  the 
symmetry  of  the  cord  becomes  altered. 

Microscopic  examination  shows  that  in  the  earlier  stages  the 
nerve  fibres  are  exclusively  affected.  The  medullary  sheaths 
undergo  fatty  degeneration  and  ultimately  disappear,  while  there 
is  a  considerable  development  of  granule  cells,  but  the  axis  cylin- 
ders are  said  to  persist  for  some  time  afterwards.  Secondary 
degeneration  of  the  pyramidal  tract  has  been  found  in  the  spinal 
cord  by  Hom^n  ^  twenty-three  days  after  the  occurrence  of  an 
apoplectic  attack,  and  he  believes  that  the  primary  changes  take 
place  in  the  axis  cylinders. 

In  the  later  stages  of  degeneration  the  nerve  fibres  disappear 
entirely;  the  neuroglia  is  increased  in  quantity,  and  changes  into 
a  dense  finely  fibrillated  tissue,  which  contains  numerous  nuclei 
and  spindle  cells. 

1.  History. — Secondary  atrophy,  extending  to  the  pons  and  pyramids  of 
the  medulla,  was  observed  in  disease  of  the  brain  by  Cruveilhier  and 
Kokitansky,  but  tbey  did  not  follow  it  to  the  spinal  cord.  Tiirck^  made  a 
thorough  examination  of  the  secondary  degenerations  of  the  spinal  cord  in 
1851  and  1853,  and  their  histological  characters  were  investigated  in  1863 
by  Leyden.s  Various  French  authors,  as  Charcot,  Cornil,  and  others,  pub- 
lished cases  in  which  these  degenerations  were  observed,  but  the  most 
exhaustive  work  on  the  pathology  of  the  affection  was  published  by  Bouchard* 
in  1866.     Soon  afterwards  Westphal"  showed  that  secondary  degenerations 

'  Homen  (E.  A.).  "  Ueber  secundare  Degeneration  im  verlangerten  Mark  und 
Kiickenmark."    Virchow's  Arch.,  Bd.  LXXXVIII.,  1882,  p.  69. 

*  Tiirck  (L.).  "Ueber  secundare  Erkrankung  einzelner  Riickenmarksstrange 
und  ihre  Fortsetzungen  zum  Gehirn."  Sitzungsber.  d.  kais.  Akadm.  d.  Wiss. 
Matthem.-Naturw.  Classe,  Bd.  VI.,  1851,  p.  288 ;  Bd.  XI.,  1853,  p.  93. 

^  Leyden.  "  Ueber  graue  Degeneration  dea  Eiickenmarks."  Deutsch.  Klinik., 
1863,  Nr.  13. 

*  Bouchard.  "Des  degenerations  secondaires  de  la  moelle  ^piniere."  Arch. 
g^n^r.  de  m^d.,  Tome  I.,  1866,  pp.  272,  441,  561 ;  Tome  II.,  1866,  p.  273. 

*  Westphal  (C).  "Ueber  kunstliche  erzeugte  secondare  Degeneration  einzelner 
Eiickenmarksstrange."    Virchow's  Arch.,  Bd.  XL VIII.,  1869,  p.  516. 


SPINAL  CORD  AND   MEDULLA   OBLONGATA. 


845 


could  be  produced  experimentally  in  dogs,  and  this  was  afterwards  confirmed 
by  Vulpian. 

2.  Bistribution  of  the  Degeneration. — The  observations  of  Charcot  and 
Pierrot,^  and  subsequently  of  Flechsig,^  tend  to  show  that  these  secondary 
degenerations  of  the  spinal  cord  are  determined  by  the  order  of  its  develop- 
ment. The  development  of  the  embryological  systems  of  the  white  sub- 
stance of  the  cord  aflfords  a  good  illustration  of  the  law  of  evolution,  while 
the  secondary  degenerations  afford  an  almost  eqxially  good  illustration  of 
the  law  of  dissolution.  The  distribution  of  these  degenerations,  therefore, 
may  be  readily  understood  by  reference  to  Fiffs.  152  to  156,  which  illustrate 
the  development  of  the  cord. 

(a)  Ascending  degeneration  takes  place  above  the  seat  of  the  lesion  in 
the  columns  of  GoU  {Figs.  175  to  177,  g),  and  terminates  in  the  upper  end 
of  the  medulla  oblongata,  where  the  fibres  end  in  the  cuneate  nucleus. 
The  direct  cerebellar  fibres  also  undergo  ascending  degeneration  {Figs.  175 
and  176,  dc).  It  may  begin  as  a  thin  lamella  of  degenerated  tissue  on  the 
external  surface  of  the  lateral  column  in  the  lower  dorsal  region,  the  area  of 
the  degeneration  gradually  increasing  in  size  upwards  along  the  cord  and 
the  external  surface  of  the  restiform  bodies.^  A  case  is  reported  by 
Gowers^  in  which  the  lower  extremity  of  the  cord  was  crushed  by  a  fracture 
of  the  spine,  and  in  which,  in  addition  to  the  ascending  degeneration  of  the 
column  of  Goll,  a  small  area  of  degeneration  was  observed  in  each  anterior 
root-zone  in  front  of  the  lateral  pyramidal  tract,  the  latter  being  healthy  on 
both  sides.  Dr.  Gowers  suggests  that  these  fibres  constitute  a  part  of  the 
sensory  conducting  paths.  Small  circumscribed  areas  of  degeneration  have 
been  found  by  Dr.  Hadden,^  which  occupied  symmetrical  positions  in  the 


Fig.  175. 


Fig.  176. 


Fig.  177. 


Figs.  175,  176,  and  177.  Transverse  Sections  of  the  Spinal  Cord,  from  the  middle  of 
the  cervical  enlargement,  middle  of  the  dorsal  region,  and  middle  of  the  lumbar 
region  respectively,  showing  ascending  degeneration  of  the  column  of  Goll  {g), 
and  of  the  direct  cerebellar  tract  [dc). 


*  See  Charcot,  Lemons  sur  lea  maladies  du  systeme  nerveux.  Tome  IL, 
2eEdit.,  1877,  p.  215. 

*Flechsig  (P.).  "Ueber  Systemerkrankungen  von  Riickenmark."  Arch.  f. 
Heilkunde,  Bd.  XVIII.,  1877,  p.  289. 

'  See  Bastian  (C).  "Case  of  concussion-lesion  with  secondary  degenerations  of 
the  spinal  cord  and  general  muscular  atrophy."  Medico-Chir.  Transactions,  Vol. 
L.,  1867  (Plate  IX.),  p.  499  et  seq. 

*  Growers  (W.  E..).  Diagnosis  of  the  spinal  cord.  2nd  Edit.,  1881,  p.  13,  Plate, 
Fig.  3. 

*  Hadden  (W.  B.).  "  Symmetrical  degeneration  in  the  spinal  cord  and  medulla 
oblongata."    Transactions  of  the  Pathological  Society  of  London,  1882. 


846 


MORBID  ANATOilY  OF   THE 


anterior  root-zones  in  the  upper  part  of  the  cervical  region  and  lower  part 
of  the  medulla,  but  his  observation  loses  much  of  its  value,  inasmuch  as 
the  clinical  history  of  the  case  could  not  be  obtained.  In  lesions  of  the 
Cauda  equina,  and  sometimes  after  severe  traumatic  injuries  of  the  sciatic 
nerve,  the  posterior  root-zones,  as  well  as  the  columns  of  Goll,  undergo 
ascending  degeneration  in  the  lumbar  and  greater  portion  of  the  dorsal 
regions,  but  the  degeneration  becomes  limited  to  the  columns  of  Goll  in  the 
upper  dorsal  and  cervical  regions.  Cases  of  this  kind  have  been  described 
by  Cornil,^  Lange,^  Simon,^  Leyden,*  and  two  such  have  come  under  my  own 
observation. 

(b)  Descending  degeneration  occiu-s  in  all  destructive  lesions  of  the  brain 
or  spinal  cord  which  injure  the  fibres  of  the  pyramidal  tract  in  their 
passage  through  the  corona  radiata,  internal  capsule,  crus  cerebri,  pons, 
medulla,  or  cord.  In  the  diseases  of  the  cord,  the  degeneration  is  generally 
bilateral  and  S}Tn metrical,  and  the  position  occupied  by  the  diseased  por- 
tions of  the  cord  in  the  lateral  columns  is  represented  in  Figs.  178,  179, 
and  180^ ;  the  degeneration  of  the  columns  of  Tiirck  is,  however,  not  shown. 
The  position  occupied  by  the  diseased  portion  in  the  medulla  oblongata  is 
represented  in  the  annexed  woodcut  {Fig.  181,  A).  In  cerebral  lesions  the 
degenerative  tract  is  generally  hmited  to  one  side — the  side  of  the  cord 
opposite  the  lesion  in  the  brain — as  represented  in  Figs.  182  to  184.  The 
columns  of  Tiirck  on  the  same  side  as  the  lesion  of  the  brain  are  also 
usually  simultaneously  degenerated,  but  this  is  not  represented  in  the 
figure.  A  descending  degeneration  of  the  fXlet  has  recently  been  described 
in  cases  of  focal  lesions  of  the  lateral  half  of  the  pons.    In  a  case  reported  by 


Fig.  178. 


Fig.  179. 


Fig.  180. 


Figs.  178.  179,  and  180  'after  Charcot).  Transverse  Sections  of  the  Spinal  Cord,  from, 
the  middle  of  the  cervical  enlargement,  raiddlc  of  the  dorsal  region,  and  middle  of 
the  lumbar  region  respectively,  showing  primary  lateral  sclerosis  cf  the  cord,  or 
secontfiary  to  a  lesion  high  up  in  the  cord  or  medulla  oblongata. — A,  A,  A,  De- 
generated pyramidal  tracts. 

'See  Erb  (A.).  "Diseases  of  the  spinal  cord."  Ziemssen's  Cyclopaedia,  Vol. 
XIII.,  1878,  p.  764. 

*  Lange  (C).     Virchow's  Jahresb.    Bd.  II.,  1872,  p.  79. 

^  Simon  (Th.).  "Tumor  im  Sack  der  Dura  spinalis,  die  cauda  equina  compri- 
mirend,  mit  fortgeleiter  Degeneration  der  Hinterstrange  bis  in  das  verlangerte 
Mark."    Arch.  f.  Psychiat.,  Bd.  V.,  1874,  p.  108. 

■*  Leyden.     Klinik  der  Ruckenmarkskrankheiten.     Bd.  II.,  1875,  p.  307. 

*  See  Charcot  (J.  M. ).  Le9ons  sur  les  localisations  dans  les  maladies  du  cerveau, 
Paris,  1876,  p.  160  ;  et,  Le9on8  sur  les  maladies  du  systeme  nerveaux,  Tome  II., 
2e  Edit.,  1877,  p.  221. 


SPINAL   CORD  AND   MEDULLA  OBLONGATA. 


847 


Homen^  a  focus  of  softening  was  found  in  the  lateral  half  of  the  upper  part 
of  the  pons,  and  the  pyramidal  tract  of  that  side  was  degenerated  below 
the  seat  of  the  lesion.     The  internal 

division  of  the  fillet  was  also  degene-  ^^^-  •'^^■'■• 

rated  below  the  lesion  as  far  as  to 
the  lower  end  of  the  medulla,  the 
streak  of  degeneration  being  situated 
in  the  portion  which  lies  to  the  inner 
side  of  the  olivary  body  (ii%.  161,  ar). 
A  somewhat  similar  case  is  recorded 
by  Meyer  ^  from  the  clinic  of  Kuss- 
maul.  A  focus  of  softening  was 
found  in  this  case  in  the  lateral  half 
of  the  lower  part  of  the  pons  which 
embraced  the  nucleus  of  the  sixth 
nerve,  the  formatio  reticularis,  and 
the  superior  olivary  body.  Above  the 
level  of  the  focus  there  was  secondary 
degeneration  of  the  fillet  as  far  as  to  the  posterior  ganglion  of  the  corpora 
quadrigemina,  while  below  the  level  of  the  lesion  the  internal  division  of 
the  fillet  and  the  olivary  body  were  degenerated.  The  degeneration  of  the 
fillet  could  be  traced  down  to  the  level  of  the  decussation  of  the  pyramidal 
tracts,  and  immediately  below  this  level  it  was  represented  by  a  small  spot 
of  degeneration  near  the  periphery  of  the  external  division  of  the  anterior 
root-zone,  immediately  behind  the  anterior  nerve  roots.  A  descending 
degeneration  of  the  superior  peduncle  of  the  cerebellum  has  been  observed 
secondary  to  a  focal  lesion  of  the  optic  thalamus,  but  this  form  of  degenera- 
tion will  be  described  when  we  come  to  consider  the  brain  and  its  diseases. 


Fig.  181  (after  Charcot).  Transverse 
Section  of  the  Medulla  Obloncmta,  on  a 
level  with  the  middle  of  the  olivary 
body. — A,  A,  Sclerosis  of  the  anterior 
pyramids. 


Fig.  183. 


Tigs.  182,  183,  and  184  (after  Charcot).  Transverse  Sections  of  the  Spinal  Cord,  from 
the  middle  of  the  cervical  enlargement,  middle  of  the  dorsal  region,  and  middle  of 
the  lumbar  region  respectively,  showing  descending  sclerosis  of  the  pyramidal 
tract  in  the  lateral  column  secondary  to  a  cerebral  lesion. — A,  A,  A,  De- 
generated pyramidal  tract. 

3.  Degeneration  of  the  Spinal  Cord  Secondary  to  Amputation. — The 
changes  which  occur  in  the  spinal  cord  after  amputation  have  been  studied  • 


'  Hom^n  (E.  A.\  "Ueber  secundare  Degeneration  im  verlangerten  Mark  und 
Eiickenmark."    Virchow's  Archiv.,  Bd.  LXXXVIII.,  1882,  p.  61. 

*  Meyer  (P.).  "  Ueber  einen  Fall  von  Ponsbamorrhagie  mit  secundaren 
Degeneration  en  der  Schleife."    Arch.  f.  Psychiat.,  Bd.  XIIL,  1882,  p.  63. 


848  MOEBID  ANATOMY  OF  THE 

by  Dickinson,^  Lockhart  Clarke,^  Vulpian,^  Genzmer,*  and  Leyden,®  and 
Dr.  Dreschfeld^  has  given  a  good  resume  of  the  previous  observations  of 
others,  while  adding  new  observations  of  his  own.  The  general  result  appears 
to  be  that  the  peripheric  nerves  and  the  white  substance  of  the  cord  are  un- 
affected, the  posterior  roots  are  often  slightly  diminished  in  size,  and  changes 
in  the  ganglion  cells  of  the  anterior  horns  are  of  constant  occurrence.  Some 
of  the  ganglion  cells  of  the  anterior  horns  have  completely  disappeared, 
whilst  those  that  remain  are  atrophied  and  shorn  of  their  processes. 
Judging  from  the  various  drawings,  the  ganglion  cells  of  the  margins 
of  the  various  groups  disappear  first,  and  those  of  their  centres  remain 
to  the  last.  The  cells  of  the  postero-lateral  group  are  particularly  liable 
to  be  affected.  No  mention  is  made  of  the  disappearance  of  any  of 
the  ganglion  cells  from"  the  anterior  horn  on  the  side  opposite  to  that  of 
the  amputated  limb ;  but  judging  from  the  diagrams  which  illustrate  Dr. 
Dreschfeld's  paper,  I  should  think  that  the  number  of  cells  in  the  internal 
group  of  the  opposite  side  is  much  diminished.  The  fibres  of  the  external 
fasciculus  of  the  posterior  root  pass  through  the  anterior  commissure  to 
join  the  cells  of  the  internal  group,  and  in  future  cases  it  would  be  worth 
while  to  observe  whether  a  streak  of  degeneration  might  not  be  detected 
along  the  course  of  these  fibres  to  reach  the  internal  group  of  the  opposite 
side.  Hayem''  tore  out  the  sciatic  nerve  of  one  side  in  rabbits,  and  found 
in  the  lumbar  region  of  the  cord  on  the  same  side  sclerosis  of  the  posterior 
root  and  posterior  grey  matter,  along  with  degenerative  atrophy  of  the 
ganglion  cells  of  the  intermedio-lateral  tract. 


(0)  Deformities  and  Malformations  of  the  Spinal  Cord. 

§  384.  The  deformities  and  malformations  of  the  spinal  cord 
may  be  subdivided  into — (l.)  the  congenital  deformities  which 
are  incompatible  with  the  maintenance  of  extra-uterine  life ; 
(il.)  the  congenital  deformities  which  are  compatible  with  life, 
and  do  not  betray  themselves  by  any  symptom  during  life ;  (ill.) 

*  Dickinson,  "  On  the  changes  in  the  nervous  system  which  follow  the  amputa- 
tion of  limbs."  Journal  of  Anatomy  and  Physiology,  Vol.  III.,  Nov.,  1868,  p.  88; 
and  Transactions  of  the  Pathological  Society,  Vol.  XXIV.,  1873,  p.  2. 

"^  Clarke  (Lockhart).     Medico-Chirurgical  Transactions.    Vol.  LI.,  1868,  p.  257. 

^  Vulpian.  "Influence  de  I'abolition  des  fonctions  dea  nerfs  sur  la  region  de  la 
moelle  epiniere  qui  leur  donne  origine.  Examen  de  la  moelle  6piniere  dans  des  cas 
d'amputation  d'ancienne  date."  Arch,  de  Physiol.,  1868,  p.  443.  And  "  Sur  Jes 
modifications  qui  se  produisent  dans  la  moelle  Epiniere  sous  I'influence  de  la  section 
des  nerfs  d'un  membre."    Arch,  de  Physiologic,  1869,  p.  675. 

■*  Genzmer.     Virchow's  Archiv.     Bd.  LXVI. ,  1876. 

*  Leyden.    Klinik  der  Riickenmarkskrankheiten.     1875.     Bd.  II.,  p.  316. 

"  Dresohfeld  (J.).  "On  the  changes  in  the  spinal  cord  after  amputation  of 
limbs."    Journal  of  Anatomy  and  Physiology,  Vol.  XIV.,  1879,  p.  424. 

^  Hayem.  "Des  alterations  de  la  moelle  cons^cutives  A.  I'arrachement  du  nerf 
sciatique  chez  la  lapin."    Arch,  de  Physiologie,  Tome  V.,  1873,  p.  504. 


SPINAL   CORD  AND'  MEDULLA  OBLONGATA.  849 

the  congenital  deformities  which  may  be  recognised  during  life  ; 
(iv.)  acquired  deformities  resulting  from  pathological  processes 
(Syringomyelia,  Hydromyelus  acquisitus). 

The   following  are  the   more   frequent   conditions   observed 
(Leyden) : — 

(I.)    CONGENITAL   DEFORMITIES   OP   STILL-BORN   CHILDREN. 

(1)  Amyelia,  or  absence  of  the  spinal  cord.  It  is  only  met  with  when 
the  brain  is  also  absent. 

(2)  Atelomyelia,  or  imperfect  development  of  the  spinal  cord.  The 
upper  end  of  the  cord  is  lacking  or  imperfectly  developed,  the  brain  being 
also  absent  (anencephalia),  or  the  head  defective  (acephalia).  The  medulla 
oblongata  is  absent  or  exists  only  in  a  rudimentary  form. 

(3)  Diastematomyelia  is  a  condition  in  which  the  two  lateral  halves  of 
the  cord  either  do  not  unite,  or  unite  only  throughout  a  portion  of  their 
extent.     This  malformation  occm-s  with  anencephalia. 

(4)  Diplomyelia,  or  duplication  of  the  spinal  cord,  appears  in  the  various 
forms  of  double  monsters. 

(II.)    CONGENITAL   DEFORMITIES    WHICH    CANNOT  BE   RECOGNISED   DURING 

LIFE. 

(1)  Anomalies  in  the  Length  and  Thickness  of  the  Cord. — The  cord  is 
foimd  at  times  thick  and  voluminous,  and  at  other  times  thin  and  small. 
It  descends  at  times  to  the  third  lumbar  vertebra,  and  ends  at  other  times 
opposite  the  eleventh  or  twelfth  dorsal.  Abnormal  smaUness  of  the  entire 
spinal  cord  and  medulla  oblongata,  with  corresponding  smaUness  of  the 
nerve  fibres  and  axis  cylinders,  has  recently  been  described  by  F.  Schultze, 
in  one  of  Friedreich's  cases  of  "  hereditary  ataxy." 

(2)  Asymmetry  of  the  grey  substance,  showing  unequal  width  and  depth 
of  the  anterior  grey  horns  on  a  transverse  section.  In  cases  of  congenital 
absence  or  intra-uterine  arrest  of  development  of  certain  extremities 
atrophy  of  definite  portions  of  the  spinal  cord  may  be  observed,  which  is 
limited  to  the  cervical  or  lumbar  enlargement  according  to  the  extremity 
afiected.  Serres^  found  in  two  embryos  in  which  the  lower  extremities 
were  wanting  an  absence  of  the  lumbar  enlargement  of  the  spinal  cord, 
while  the  cervical  enlargement  was  well  developed.  In  a  case  of  arrest  of 
development  of  the  forearm  and  congenital  absence  of  the  right  hand 
described  by  Troisier  ^  there  was  a  considerable  diminution  of  the  right 
lateral  half  of  the  cervical  enlargement  of  the  spinal  cord,  the  diminution 
in  volume  being  chiefly  limited  to  the  grey  substance.  In  a  case  of  con- 
genital defect  of  the  right  forearm  and  hand — perobrachia — observed  by 

'  Serres  (E.  R.  A.).  Anatomie  compar^e  du  cerveau.  Tome  II.,  Paris,  1824- 
1826,  p.  166  eb  seq. 

'  Troisier.  "  Note  sur  I'etat  de  la  moelle  epiniere  dans  un  cas  d'hemim41ie  uni- 
thoracique."    Arch,  de  Physiologie,  1871-72,  p.  72. 

VOL.  I.  CCC 


850 


MORBID  ANATOMY  OF  THE 


Davida/  the  anterior  and  posterior  roots,  with  the  corresponding  spinal 
ganglia,  of  the  right  half  of  the  spinal  cord,  from  the  sixth  cervical  to  the 
first  dorsal  inclusive,  were  much  thinner  and  contained  a  smaller  number 
of  fasciculi  than  those  of  the  left  side.  In  a  similar  case  described  by 
Edinger,^  in  which  the  left  hand  and  forearm  were  defective,  the  nerve 
roots  from  the  fifth  to  the  eighth  cervical  were  thinner  on  the  left  than  on 
the  right  side,  and  the  corresponding  parts  of  the  anterior  and  posterior 
grey  horns  were  also  atrophied,  and  on  a  level  with  the  sixth  and  seventh 
nerves  it  was  almost  impossible  to  trace  the  cells  or  their  processes  on  the 
aflfected  side. 

In  a  case  of  congenital  talipes  equino-varus  of  both  legs,  I  found  the 
conus  meduUaris  remarkably  thin  and  tapering.  On  transverse  section 
the  anterior  grey  horns  were  seen  to  be  deformed,  the  internal  border, 
which  normally  runs  parallel  with  the  anterior  fissure,  being  drawn  out- 
wards and  backwards,  so  as  to  be  almost  in  a  line  with  the  anterior  border  of 

Fig.  185. 


I'iG.  185.  Transverse  Section  of  the  upper  end^of  the  Conus  MeduUaris  of  the  Spinal 
Cord,  from  a  case  of  congenital  talipes  equino-varus. — A,  P,  Anterior  and  posterior 
horns  respectively ;  i,  internal  group  showing  healthy  cells ;  a,  anterior,  ol, 
antero-lateral,  pi,  postero-lateral,  and  c,  central  groups  of  cells,  each  being 
represented  only  by  a  few  small  round  cells  without  processes. 

■  Davida.  ' '  ITeber  der  Verhalten  der  Spinal wurzeln  und  Spinalganglien  der  Hals- 
nerven  in  einem  Falle  von  Perobrachie."  Virchow's  Archives,  Bd.  LXXXVIII., 
1882,  p.  99. 

^  Edinger.  "  Riickenmark  Und  Gehirn  in  einem  Fall  von  angeborenem  Mangel 
eines  Vorderarmes."    Virchow's  Archives,  Bd.  LXXXIX.,  1882,  p.  46. 


SPINAL   CORD   AND  MEDULLA  OBLONGATA.  851 

the  anterior  commissure.  The  ganglion  cells  of  the  internal  group  were  well 
developed,  although  it  was  displaced  from  its  usual  position  {Fig.  185,  i). 
A  few  cells  were  observed  in  the  postero-lateral  area  ;  but  the  cells  of  the 
anterior,  central,  and  antero-lateral  groups  were  entirely  absent  in  many 
sections,  while  in  others  a  few  imperfectly-developed  cells  were  observed  in 
these  areas  {Fig.  185,  a,  c,  al).  The  fine  fibriUated  texture  of  Gerlach's 
network  and  the  smaU  glistening  nuclei  of  the  neuroglia  appeared  to  have 
been  replaced  by  a  loose  connective  tissue,  thickly  studded  with  connective- 
tissue  corpuscles.  Mr.  Hardie^  long  ago  maintained  that  congenital  tahpes 
is  due  to  an  arrest  of  development,  and  that  the  feet  occupy  postures 
similar  to  those  of  the  embryo. 

Unusual  outgrowths  or  absence  of  portions  of  the  grey  matter,  such  as 
of  the  tractus  intermedio-lateralis,  are  occasionally  met  with.  Duplica- 
tions of  one  of  the  grey  horns  for  a  longer  or  shorter  distance  have  also 
been  observed. 

(3)  Ahno7-malities  of  the  Pyramidal  Tracts.  — Flechsig  has  recently 
shown  that  the  fibres  of  the  pyramidal  tracts  are  very  variable  in  their 
distribution.  Each  pyramid  may  send  its  mass  of  fibres  into  the  spinal 
cord,  either  entirely  crossed  or  only  partly  crossed,  or  down  the  anterior 
columns  almost  entirely  uncrossed.  These  tracts  are  absent  in  anence- 
phalous  monsters,^  and  they  are  imperfectly  developed  in  some  cases  of  the 
arrest  of  development  of  portions  of  the  cerebral  hemispheres  which  have 
been  termed  poi-encephalus.^ 

(IIL)  CONGENITAL  DEFORMITIES  WHICH  MAT  BE  RECOGNISED  DURING  LIFE. 

(1)  Congenital  Enlargement  of  the  Central  Canal,  a  condition  which  has 
been  variously  called  hydrorrhachis  interna,  hydromyelus,  or  hydromyelus 
congenitus.  In  the  lighter  grades  of  the  congenital  affections  the  central 
canal  in  the  foetus  is  converted  into  a  cavity  varying  in  width  from  that  of 
an  ordinary  knitting  needle  to  that  of  a  crow's  quill.  The  canal  may  extend 
the  entire  length  of  the  cord,  but  is  at  other  times  restricted  to  certain 
portions,  generally  the  cervical  or  lumbar  enlargement,  while  the  dilatation 
may  occasionally  be  moniliform,  or  the  anterior  and  posterior  walls  may 
have  grown  together  across  the  middle  giving  rise  to  the  appearance  of  a 
double  canal.  The  cord  does  not  appear  to  imdergo  any  abnormal  changes 
apart  from  the  displacement  of  its  various  segments  occasioned  by  the 
great  dilatation  of  the  canal. 

In  the  higher  grade  of  congenital  hydromyelus  either  the  spinal  cord 
disappears  entirely,  or  becomes  split  into  two  halves  for  a  greater  or  lesser 
distance,  while  the  cavity  of  the  central  canal  communicates  freely  with 

1  Hardie  (J.).     British  and  Foreign  Medico-Chir.  Review.    Vol.  I.,  1871,  p.  477. 

^  riechsicr.  "  Ueher  Systemerkrankungen  im  Riickenmark."  Arch.  f.  Heil- 
kunde,  Bd.  XVIII.,  1877,  p.  468. 

^  See  Kundrat.  Die  Porencephalic,  eine  anatomische  Studie.  Graz,  1882,  pp. 
45  and  101.  And  Ross  (J.).  "  On  the  spasmodic  paralyses  of  infancy."  Brain, 
Vol.  v.,  1882-3,  p.  475. 


852  MORBID  ANATOMY  OF  THE 

the  cavity  of  the  spinal  arachnoid ;  the  hydrorrachis  interna  is  then  merged 
into  hydrorrachis  externa,  as  not  luafrequently  happens  in  spina  bifida. 

(2)  Spina  bifida  consists  of  an  abnormal  accumulation  of  fluid  within 
the  cavity  of  the  spinal  arachnoid,  associated  with  a  greater  or  lesser  defor- 
mity of  the  vertebral  column.  As  it  gives  rise  to  serious  symptoms  during 
life,  it  will  be  subsequently  described  in  detail  along  with  the  diseases  of 
the  membranes  of  the  spinal  cord. 

(IV.)  ACQUIRED  DEFORMITIES  RESULTING  FROM  PATHOLOGICAL  PROCESSES. 

(1)  Syringomyelia,  or  the  pathological  formation  of  cavities  may  be 
caused  in  various  ways. 

(a)  Cavities  are  formed  by  the  softening  of  the  central  portions  of  new 
formations,  such  as  gliomata,  ghomyxomata,  and  gliosarcomata.  The 
tumoiu"  is  sometimes  so  completely  disintegrated  that  only  a  capsule  of 
connective  tissue  or  mere  traces  of  it  remain.  This  softening  is  sometimes 
initiated  by  haemorrhage  into  the  interior  of  the  tumour.  This  accident 
is  particularly  apt  to  occur  in  the  teleangiectatic  varieties. 

Q})  Breaking  down  and  softening  of  apoplectic  foci. 

(c)  Central  softening  in  areas  of  grey  degeneration  and  chronic 
myelitis. 

(d)  Obstruction  of  lymph  channels  produced  by  the  pressure  of  a 
tumour  and  other  causes  (Westphal).  Cavities  have  been  formed  in  the 
spinal  cords  of  animals  subsequent  to  various  injuries,  and  these  have 
been  su]3posed  to  have  been  caused  by  obstruction  of  lymph  channels 
(Naunyn  and  Eichhorst). 

(2)  Hydromi/elxhs  acquisitus,  or  acquired  dilatation  of  the  central  canal, 
may  result  from  the  following  causes  : — 

(a)  Peri-ependymal  myelitis,  which  consists  of  a  proliferation  of  the 
connective  tissue  surrounding  the  central  canal,  may  cause  secondary 
dilatation  by  the  shrinking  of  the  newly-formed  tissue  (Hallopeau). 

(6)  Chronic  meningitis,  by  producing  adhesions  of  the  pia  mater  to 
the  dura  mater  at  definite  points,  may  also  cause  dilatation  of  the  central 
canal,  probably  by  shrinking  of  the  newly -formed  tissue  (Simon). 

(c)  Obliteration  of  the  canal  at  one  point  may  lead  to  dilatation  of  the 
neighbouring  portions. 

The  cavities  vary  greatly  in  size.  They  may  indeed  be  only  a  few 
millimetres  in  length,  or  extend  the  entire  length  of  the  cord.  Their 
number  also  varies  ;  in  many  cases  one  only  is  found,  but  at  other  times  a 
large  mmiber  of  them  may  be  present.  They  are  almost  always  situated 
near  the  centre  of  the  cord,  and  their  relations  to  the  central  canal  can  only 
be  determined  by  careful  examination.  The  transverse  diameter  of  these 
cavities  may  vary  from  that  of  a  needle  to  the  tip  of  a  man's  little  finger. 
On  transverse  section  their  form  is  roundish,  oval,  or  angular,  and  their 
contents  consist  of  Ught  and  clear  or  turbid  and  yellowish  fluid. 

The  walls  of  the  cavities  may  be  smooth  and  firm,  and  are  often  lined 
with  a  layer  of  cylindrical  epithelium,  or  they  may  be  rough,  ragged,  and 


SPINAL  COKD  AND  MEDULLA  OBLONGATA.  853 

uneven.  Their  walls  may  also  be  dense,  and  formed  of  cirrhotic  tissue  or  of 
tissue  which  has  undergone  grey  degeneration,  or  of  the  various  new 
formations  which  have  already  been  described. 

The  symptoms  caused  by  the  formation  of  cavities  in  the  cord  depend 
entirely  upon  their  situation,  and  no  definite  disease  which  can  be  recog- 
nised during  life  can  be  ascribed  to  their  presence. 


(D)  The  Law  of  Dissolution  as  Esemplified  bt  the  Morbid  Changes 
OF  THE  Spinal  Cord  and  Medulla  Oblongata. 

§  885.  Let  us  now  pass  from  the  details  of  the  morbid  changes 
of  the  cord  to  the  general  principles  which  underlie  them.  In 
accordance  with  the  law  of  dissolution  (§  35)  we  may  expect 
that  the  accessory  portions  of  the  cord  will  form  parts  of  least 
resistance  to  the  inroads  of  disease. 

In  the  grey  substance  the  least  resistance  to  disease  will  be 
oflfered  by  the  central  column,  which  is,  as  we  have  already 
seen,  the  embryonic  area  of  the  cord,  and  by  the  median  area 
of  the  anterior  grey  horn  in  the  lumbar  and  cervical  enlarge- 
ments and  the  medio-lateral  area  in  the  dorsal  and  upper  cervical 
regions — areas  which,  as  already  remarked,  may  be  regarded  as 
outgrowths  of  the  central  column.  These  areas  contain  the 
accessory  nuclei  of  the  spinal  cord,  and  since  these  ganglion  cells 
not  only  are  developed  at  a  comparatively  late  period,  but  also 
frequently  maintain  a  relatively  small  size  in  the  adult,  the 
resistance  offered  to  the  invasion  of  disease  becomes  still  less. 
This  law  must  necessarily  be  true  whether  the  disease  begin  in 
the  ganglion  cells  themselves,  in  the  neuroglia,  or  in  the  vessels, 
or  whether  it  be  caused  by  a  poison  circulating  in  the  blood, 
provided  that  the  poison  possess  no  special  afi&nity  for  any  one 
set  of  the  ganglion  cells  more  than  for  others. 

The  cell  walls  of  the  small  and  recently-developed  cells  are 
much  thinner  than  those  of  the  larger  and  earlier-developed 
cells,  hence  the  exchange  of  materials,  which  is  the  necessary 
accompaniment  of  nutrition,  takes  place  more  readily  in  the 
former  than  in  the  latter.  But  this  is  not  all.  A  large  cell 
presents,  in  proportion  to  its  bulk,  a  smaller  surface  to  its 
environment  for  the  absorption  of  nourishment  than  a  small  cell, 
and  consequently  the  relative  amount  of  nourishment  absorbed 
by  the  large  will  be  less  than  that  absorbed  by  the  small  cell 


854  MORBID   ANATOMY   OF  THE 

(§  9).  But  high  nutritive  activity  is  associated  with  great  in- 
stability, which  declares  itself  in  increased  readiness  to  give  out 
energy  or  to  multiply,  the  latter  process,  of  course,  involving  the 
disorganisation  of  a  highly-organised  tissue. 

When,  therefore,  the  ganglion  cells  of  the  anterior  horns 
become  diseased,  it  may  be  expected  that  the  later-developed 
and  small  cells  will  be  the  first  to  suffer,  and  when  a  poison 
like  strychnine  circulates  in  the  blood,  the  same  cells  will  also 
be  the  first  to  be  affected,  supposing  the  drug  not  to  possess  a 
special  affinity  for  one  ganglion  cell  more  than  for  another. 
The  reason  of  this  is,  that  the  quantity  of  the  poison  which 
will  enter  the  substance  of  the  small  cell  will  be  much  larger 
in  proportion  to  its  bulk  than  that  which  -vvill  enter  into  the 
substance  of  the  large  cell.  If  the  disease  begin  in  the  neu- 
roglia, it  may  be  expected  that  the  spongy  and  loose  neuroglia  of 
the  later-developed  portions  of  the  grey  substance  will  resist  its 
inroads  less  effectually  than  the  dense  neuroglia  surrounding  the 
earlier-developed  groups  of  ganglion  cells.  The  central  grey 
column  possesses  a  loose  and  spongy  neuroglia,  and  we  have  seen 
that  it  ma^  be  regarded  as  the  embryonic  area  of  the  spinal  cord, 
so  that  i/t  may  be  expected  to  offer  little  resistance  to  the  invasion 
of  disease.  We  shall  hereafter  see  that  some  of  the  most  rapidly 
fat9yi  diseases  of  the  cord  appear  to  ascend  in  the  central  grey 
column.  In  has  been  pointed  out  that  the  later-formed  cells  of 
'the  anterior  horns  grow  close  to  the  arteries,  while  the  earlier- 
developed  cells  are  pushed,  in  the  course  of  development,  away 
from  them.  When,  therefore,  rapid  exudation  takes  place  from  the 
vessels,  whether  it  consist  of  a  fluid  and  granular  exudation  or 
of  migration  of  white  blood  corpuscles,  the  cells  in  the  neigh- 
bourhood of  these  vessels  will  suffer  sooner  and  in  greater  degree 
than  those  more  remote. 

That  the  lines  of  least  resistance  to  disease  in  the  lumbar 
region  are  in  the  direction  of  the  vessels  is  well  illustrated  by 
Fig.  186,  which  is  taken  from  a  section  of  the  middle  of  the 
lumbar  enlargement  in  a  case  of  infantile  paralysis,  under  the 
care  of  Dr.  Humphreys  at  the  Pendlebury  Hospital  for  Sick 
Children.  This  case  is  described  in  the  "Transactions  of  the 
Pathological  Society  of  Loudon"  for  1879,  and  will  be  subse- 
quently mentioned.     My  present  object  is  to  show  that  even  in 


SPINAL   CORD  AND  MEDULLA  OBLONGATA. 


855 


an  acute  disease  like  infantile  paralysis  the  cells  near  the  vessels 
have  become  destroyed  in  preference  to  the  others.  If  Fig.  186 
be  compared  with  Fig.  134,  it  will  be  seen  at  once  that  the 
disease  is  most  marked  in  the 

vascular  areas  of  the  cord,  and  '        '  ^,..^. 

that  the  cells  which  have  been  ^^^ 

last  developed  are,  on  the  whole, 
those  which  have  suffered  most 
will  be  apparent  by  referring 
to  the  previous  description  and 
illustrations  of  the  development 
of  the  cord.  It  is  true  that  the 
earlier-developed  cells  of  the  in- 
ternal and  anterior  groups  have 
disappeared ;  but  the  cells  of 
the  antero-lateral,  and  those  of 
the  central  portions  of  the  pos- 
tero-lateral  and  of  the  central 
group  are  well  preserved ;  while 
the  marginal  cells  of  the  two 
latter  groups  and  all  the  cells  of 
the  median  area  are  completely 
destroyed.  It  is  not  likely 
that  this  law  will  always  be 
observed  in  a  disease  having 
such  an  acute  and  sudden  onset 
as  infantile  paralysis ;  but  an 
examination  of  the  diagrams 
given  by  Clarke,  Charcot,  and  Joffroy,  shows  so  many  indica- 
tions of  the  fulfilment  of  this  law  that  its  occurrence  cannot  be 
regarded  as  accidental.  The  same  law  is  observed,  at  least 
very  frequently,  in  cases  of  acute  and  subacute  ascending  cen- 
tral myelitis,  as  well  as  in  .tetanus  and  hydrophobia.  It  was 
while  examining  cases  of  this  kind  that  my  attention  was  first 
directed  to  this  subject.  In  all  the  acute  diseases  affecting  the 
grey  substance  of  the  spinal  cord  I  observed  that,  unless  the 
destruction  was  so  great  as  to  involve  the  anterior  horns  in 
their  entire  extent,  the  small  cells  and  those  in  the  line  of  the 
distribution  of  the  arteries  manifested  evidences  of  disease  to  a 


Fig.  186  'Young).  Section  of  the  Lum- 
bar Region  of  the  Spinal  Cord  from  a 
case  of  infantile  spinal  paralysis. — 
pi,  posterolateral  group;  al,  antero- 
lateral group ;  c,  central  group.  The 
internal  and  anterior  groups  have 
disappeared,  and  the  marginal  cells 
of  the  remaining  groups  are  also  de- 
stroyed. 


856 


MORBID  ANATOMY  OF  THE 


much  greater  extent  than  the  large  cells  and  those  removed 
from  the  vessels. 

The  distribution  of  the  disease  in  the  cervical  enlargement  is 
similar  to  that  in  the  lumbar  region,  except  that  the  median  area 
being  much  larger  in  the  former  than  in  the  latter,  injury  to  this 
area  forms  a  more  conspicuous  feature  of  disease  in  the  cervical 
than  in  the  lumbar  portion  of  the  cord.  When  the  dorsal  region  of 
the  cord  is  affected  by  acute  disease  of  the  grey  substance,  the  most 
marked  morbid  changes  are  observed  in  the  postero-lateral  or 
rather  the  medio-lateral  group  ;  and  the  same  is  the  case  in  the 
upper  cervical  region.  A  section  of  the  middle  of  the  cervical 
enlargement  is  represented  in  Fig.  187,  taken  from  a  case  of  sub- 
acute ascen ding  spinal  paralysis.  The  disease  began  after  exposure 
to  severe  cold  with  sudden  paralysis  of  the  lower  extremities, 
without  much  disturbance  of  sensibility.  This  was  followed  by 
rapid  wasting  of  the  muscles,  and  loss  of  faraHic  contractility. 

EiG.  187. 


Tig.  187  (Young).  Section  of  the  Middle  of  the  Cervical  Enlargement  of  the  Spinal 
Cord  from  a  case  of  central  myelitis.— i.  The  internal  group ;  the  remaining  letters 
indicate  the  same  as  the  corresponding  ones  in  Fig.  186.  The  median  area  was 
completely  destitute  of  cells,  and  a  large  number  of  the  marginal  cells  of  the 
different  groups  of  the  anterior  horn  were  destroyed  or  diseased. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  857 

The  paralysis  in  the  course  of  a  few  weeks  gradually  invaded  the 
muscles  of  the  trunk,  the  muscles  of  the  upper  extremity,  and 
ultimately  the  muscles  of  respiration.  Death  took  place  five  weeks 
from  the  commencement  of  the  paralysis.  In  the  lumbar  region 
the  white  as  well  as  the  grey  substance  was  implicated,  and  there 
was  ascending  sclerosis  of  both  the  columns  of  Goll  and  of  the 
direct  cerebellar  tracts  throughout  the  entire  length  of  the  cord; 
the  remaining  portions  of  the  white  substance  were  healthy  in 
the  dorsal  and  cervical  regions.  The  central  grey  column  was 
diseased  throughout  the  whole  length  of  the  cord,  the  cells  of  the 
postero-lateral  group  and  medio-lateral  area  having  entirely  dis- 
appeared in  the  dorsal  region,  and  again  in  the  upper  cervical 
regions;  while  the  anterior  groups  of  cells  appeared  to  be  quite 
normal.  In  the  cervical  enlargement  {Fig.  187)  the  cells  of  the 
median  area  had  entirely  disappeared,  and  the  marginal  cells  of 
the  central  and  postero-lateral  groups  were  notably  altered,  while 
the  fundamental  cells  of  the  groups  presented  beautiful  long 
processes,  and  appeared  in  every  respect  normal. 

In  the  white  substance  the  last  developed  fibres  will  also, 
other  things  being  equal,  offer  less  resistance  to  the  inroads 
of  disease  than  the  earlier-developed  fibres.  In  proceeding  to 
verify  this  statement,  we  must  compare  the  later  with  the  earlier- 
formed  fibres  of  the  same  segment,  or,  in  other  words,  the  same 
functional  system  of  the  white  substance,  otherwise  the  whole 
result  will  be  vitiated.  The  posterior  and  anterior  root-zones,  for 
instance,  are  developed  about  the  same  time,  yet  the  former  is 
more  liable  to  become  diseased  than  the  latter.  The  posterior  is 
probably  more  exposed  to  the  exciting  causes  of  disease  such  as 
peripheral  injuries  and  ascending  neuritis,  than  the  anterior  root- 
zone,  and  the  thin  fibres  of  the  former  are  more  apt  to  be  injured 
in  inflammatory  affections  of  the  cord  than  the  comparatively 
thick  fibres  of  the  latter.  But  if  the  accessory  be  compared  with 
the  fundamental  fibres  of  the  pyramidal  tract,  it  will  be  seen 
that  the  former  are  much  more  exposed  to  injurious  influences 
than  the  latter.  The  small  diameter  of  the  greater  number  of  the 
accessory  fibres  permits  a  relatively  large  amount  of  nourishment 
to  gain  access  to  their  interior  than  can  take  place  in  fibres  of 
larger  diameter ;  hence  both  reparative  and  destructive  changes 
are  more  rapidly  efiected  in  the  former  than  in  the  latter. 


858  MOKBID  ANATOMY   OF   THE 

The  accessory  fibres  are,  as  we  have  seen,  more  closely  related 
to  the  connective  tissue  septa  of  the  cord  than  the  fundamental 
fibres,  hence  the  former  are  more  liable  to  be  injured  in  the 
course  of  the  diseases  which  begin  in  the  connective  tissue  and 
neuroglia  than  the  latter.  An  appearance  which  is  presented  by 
the  spinal  cord  in  various  diseases,  and  which  for  a  long  time 
puzzled  me  very  much,  is  that  which  has  been  described  as 
miliary  sclerosis.^  This  condition  appears  to  consist  of  a  swelling 
or  thickening  of  the  septa  in  which  the  blood-vessels  run.  In 
the  lozenge-shaped  spaces  (Fig.  151)  of  the  pyramidal  tract  a 
considerable  number  of  the  small  fibres  which  lie  close  to  the 
vessels  are  destroyed,  while  the  larger  central  fibres  remain 
more  or  less  healthy.  When  a  transverse  section  of  the  cord  is 
examined  under  these  circumstances  the  part  presents  a  spotted 
appearance,  but  instead  of  the  miliary  spots  being  in  a  state  of 
sclerosis,  they  really  are  the  most  healthy  portions  of  the  section. 
The  proximity  of  the  fibres  of  the  accessory  system  to  the  blood- 
vessels renders  them  also  more  liable  than  the  fundamental 
fibres  to  be  injured  by  inflammatory  and  other  effusions. 

II.— CLASSIFICATION  OF  THE  DISEASES  OF  THE  SPINAL 
CORD  AND  MEDULLA  OBLONGATA. 

§  386.  The  rule  which  has  hitherto  been  followed  in  this  work 
is  to  describe  first  the  simplest  and  most  elementary  diseases, 
and  to  reserve  consideration  of  the  most  complicated  affections 
to  the  last.  In  no  diseases  is  it  more  advisable  to  follow  this  rule 
than  in  those  affecting  the  spinal  cord  and  medulla  oblongata, 
with  their  membranes.  The  annexed  table,  in  which  these 
diseases  are  classified,  carries  with  it  in  the  main  its  own  ex- 
planation, but  it  may  not  be  out  of  place  to  make  a  few  remarks 
with  regard  to  the  principle  adopted  in  arranging  the  structural 
diseases  of  the  nervous  organs  themselves  as  distinguished  from 
those  of  their  membranes  and  vessels,  their  functional  affections, 
injuries,  malformations,  and  neoplasms. 

It  has  already  been  found  that  the  spinal  cord  may  be  divided 
into  embryological  systems,  and  that  each  of  these  possesses  a 

'  See  Rutherford  and  Tuke.  Edinburgh  Medical  Journal,  Sept. ,  1868 ;  and 
Kesteven,  British  and  Foreign  Medieo-Chir.  Review,  October,  1869,  and  Tran- 
sactions of  the  International  Medical  Congress,  Vol.  I.,  1881,  p.  402. 


SPINAL   CORD   AND  MEDULLA  OBLONGATA.  859 

functional  unity,  and  may  he  separately  diseased.  Diseases  of 
one  of  the  functional  systems  of  the  cord  are  called  system- 
diseases  ov  fasciculated  diseases,  while  those  involving  several  of 
these  segments  may  be  called  mixed  diseases.  In  the  simple 
system-diseases  one  embryological  system  of  the  cord  and  medulla 
oblongata  alone  is  affected ;  but  it  sometimes  happens  that  two  or 
more  of  them  become  simultaneously  or  consecutively  attacked, 
and  these  affections  may  be  called  compound  system-diseases. 

The  system-diseases  may  be  divided  into  those  affecting  the 
grey  matter  or  the  poliom^yelopathies,  and  those  affecting  the 
white  matter  or  the  leucomyelopathies.  The  poliomyelopathies 
may  be  divided  into  the  diseases  affecting  the  anterior  grey 
horns,  the  central  grey  column,  and  the  posterior  grey  horns,  but 
the  latter  is  never  a  true  system-disease,  being  always  compli- 
cated by  lesions  of  other  structures,  such  as  the  posterior  roots 
and  posterior  columns.  Disease  of  the  central  column  is  also 
probably  never  observed  as  an  isolated  affection,  the  prominent 
symptoms  being  caused  by  extension  of  the  lesion  into  the 
anterior  horns,  but  we  shall  nevertheless  classify  some  at  least  of 
the  diseases  of  the  central  column  amongst  the  system-diseases. 

The  leucomyelopathies  consist  theoretically  of  diseases  of  the 
posterior  root-zone  (locomotor  ataxy) ;  of  the  anterior  root-zone, 
disease  of  which  is  probably  not  capable  of  being  separated  from 
disease  of  the  anterior  roots  and  anterior  grey  horns;  of  the 
column  of  Goll  and  the  direct  cerebellar  tract,  to  both  of  which, 
however,  no  definite  symptoms  have  been  observed  to  attach; 
and  of  the  pyramidal  tract  (primary  lateral  sclerosis). 

The  compound  system-diseases  are  probably  numerous,  but 
only  two  of  them — amyotrophic  lateral  sclerosis  and  combined 
posterior  and  lateral  sclerosis  —  are  recognised  as  distinct 
types  of  disease.  The  annexed  diagram  {Fig.  188),  copied  from 
Charcot,  represents  the  localisation  of  the  lesion  on  transverse 
section  of  the  cord  in  the  various  system-diseases.  Some  authors 
would  include  in  the  category  of  system-diseases  only  those  in 
which  the  lesion  begins  in  the  nervous  tissues  themselves,  or  the 
parenchymatous  diseases  of  the  cord.  According  to  this  strict 
definition,  it  is  probable  that  infantile  paralysis  would  require  to 
be  excluded  from  the  system-diseases.  We  shall,  however,  give 
a  considerable  latitude  to  the  definition  of  the  system-diseases. 


860 


MORBID  ANATOMY  OF  THE 


and  shall  include  not  only  all  the  diseases  in  which  the  lesion  is 
chiefly  limited  to  one  of  the  embryological  systems  of  the  cord, 
but  also  the  diseases  which  have  a  strong  clinical  affinity  with 
these,  even  although  the  lesion  is  not  strictly  limited  to  one 
system.  It  is  the  clinical  affinities  of  Landry's  paralysis,  peri- 
ependymal myelitis,  ophthalmoplegia  externa,  and  pseudo-hyper- 
trophic  paralysis,  that  alone  justifies  us  in  including  them 
amongst  the  poliomyelopathies,  but  the  practical  benefits  which 
result  from  this  classification  will,  in  my  opinion,  outweigh  any 
number  of  theoretical  objections. 

The  classification  adopted  of  the  different  forms  of  acute  and 
chronic  myelitis  does  not  require  explanation. 

Fig.  188. 


.^^ 


'^^-. 


Fig.  188  (after  Charcot).  Diagram  of  the  Morbid  Anatomy  of  the  System- Diseases  of 
the  Spinal  Cord. — A,  A,  Pyramidal  tract  of  the  lateral  column ;  A',  Columns 
of  Tiirck ;  B,  B,  Posterior  root-zones ;  C,  C,  Posterior  grey  horns ;  D,  D, 
Anterior  horn  ;  F,  F,  Anterior  root-zone ;  E,  Columns  of  Goll. 


(A)  Diseases  of  the  Spinal  Cord  and  Medulla  Oblongata. 
I.  System  diseases, 

(i.)  Poliomyelopathies. 

1.  Poliomyelitis  anterior  acuta. 

(a)  Infantile  sj)inal  paralysis. 

(b)  Atrophic  spinal  paralysis  of  adults. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  861 

2.  Paralysis  ascendens  acuta  (Landry's  paralysis). 

3.  Poliomyelitis  anterior  chronica. 

4.  Periependymal  myelitis. 

5.  Progressive  muscular  atrophy. 

6.  Labio-glosso-laryngeal  paralysis. 

7.  Ophthalmoplegia  externa. 

8.  (Pseudo-hypertrophic  paralysis.) 

(n.)  Leucomyelopathies. 

1.  Posterior  sclerosis  (Locomotor  ataxy). 

2.  Sclerosis  of  the  columns  of  GoU. 

(a)  Primary. 

(6)  Secondary  and  Ascending. 

3.  Sclerosis  of  the  direct  cerebellar  tract.     Secondary  and 

Ascending  sclerosis. 

4.  Lateral  sclerosis. 

(a)  Primary — Tabes  dorsalis  spasmodica. 

(6)  Compound — (i.)  Amyotrophic  lateral  sclerosis. 

(ii.)  Combined   posterior   and   lateral 
sclerosis, 
(c)  Secondary  and  Descending. 

II.  Mixed  diseases  of  the  spinal  cord  and  medulla  oblongata, 
(l.)  Acute  myelitis. 

1.  Acute  central  myelitis. 

2.  Hyperacute  central  myelitis  (haematomyelitis). 

3.  Acute  bulbar  myelitis. 

4.  Acute  transverse  myelitis. 

5.  Acute  hemilateral  myelitis. 

6.  Acute  myelomeningitis. 

7.  Acute  disseminated  myelitis. 

(ll.)  Chronic  myelitis. 

1.  Chronic  central  myelitis. 

2.  Chronic  transverse  myelitis. 

3.  Universal  progressive  myelitis. 

4.  Chronic  bulbar  myelitis. 

5.  Chronic  myelomeningitis. 

6.  Chronic  disseminated  myelitis  or  multiple  sclerosis, 

(ill.)  Myelomalacia. 

III.  Vascular    diseases    of    the    spinal    cord    and    medulla 
oblongata. 

(i.)  Anaemia,  Thrombosis,  and  Embolism, 
(li.)  Hypersemia  and  Haemorrhage, 


862  MORBID  ANATOMY  OF 'THE  SPINAL   CORD. 

IV".  Functional  and  secondary  diseases  of  the  spinal  cord  and 
medulla  oblongata. 

(i.)  Spinal  irritation, 
(ii.)  Neurasthenia  spinalis, 
(ill.)  Reflex  and  secondary  paraplegise. 
(iv.)  Saltatory  spasms, 
(v.)  Reflex  muscular  spasms, 
(vi.)  Intermittent  spinal  paralysis, 
(vii.)  Toxic  spinal  paralysis, 
(viii.)  Hysterical  paraplegia. 

V.  Traumatic   diseases,   tumours,   and   abnormalities    of   the 
spinal  cord  and  medulla  oblongata. 

(i )   Wounds  of  the  cord  and  of  the  medulla  oblongata, 
(ii.)  Slow  compression  of  the  cord  and  of  the  medulla 

oblongata, 
(ill.)  Hemiparaplegia  spinalis. 
(iv.)  Concussion. 

(v.)  Tumours,  and  abnormalities  of  the  spinal  cord  and 
medulla  oblongata. 

(B)    Diseases  of  the  Membranes  of  the  Spinal    Cord  and 
Medulla  Oblongata. 

I.  Vascular  diseases. 

(I.)  Hypersemia  of  the  membranes, 
(il.)  Meningeal  haemorrhage. 

II.  Inflammation  of  the  spinal  dura  mater. 

(i.)  External  pachymeningitis, 
(il.)  Internal  pachymeningitis. 

III.  Inflammation  of  the  spinal  pia  mater  and  arachnoid. 

(l.)  Acute  spinal  leptomeningitis, 
(ll.)  Chronic  spinal  leptomeningitis. 

IV.  Tumours  and  abnormalities  of  the  membranes. 


863 


CHAPTER    III. 


L— SYSTEM    DISEASES    OF    THE    SPINAL    CORD    AND 
MEDULLA    OBLONGATA. 

(I.)-P  OLIO  MYELOPATHIES. 
(1)  Poliomyelitis  Anterior  Acuta  (Kussmaul). 

Acute  Inflammation  of  tJie  Grey  Anterior  Morns — Acute  Atrophic  Spinal  Paralysis. 

§  387.  Definition. — Acute  atrophic  spinal  paralysis  begins 
suddenly,  with  or  without  fever  or  convulsions,  and  the  para- 
lysis reaches  at  once  its  maximum  of  intensity  and  extent;  it 
is  variable  in  its  distribution,  the  affected  muscles  are  flaccid, 
reflex  action  is  diminished  or  abolished,  some  of  the  muscles 
implicated  undergo  rapid  atrophy,  and  there  is  entire  absence 
of  sensory  disturbances  or  of  disorders  of  the  functions  of  the 
bladder  and  rectum. 

§  388.  History.— This  disease  was  first  mentioned  by  Underwood^  in 
1784,  but  he  did  not  separate  it  distinctly  from  other  forms  of  paralysis  to 
which  children  are  liable.  The  affection,  indeed,  does  not  appear  to  have 
attracted  much  notice  until  Heiue,^  in  1840,  directed  particular  attention 
to  it.  A  good  description  of  it  was  given  by  Barthez  and  EiUiet,^  in  1851 ; 
but  it  was  much  more  thoroughly  investigated  about  the  same  time  by 
Duchenne,^  who  named  it  paralysie  atrophique  graisseuse  de  I'enfance.  In 
1864,   two  mongraphs  appeared — the  thesis  of  Duchenne^  the  younger, 

*  See  Underwood.  Treatise  on  the  diseases  of  children.  7th  Edit,,  Lond.,  1826, 
p.  251. 

^  Heine  (J.).  Beobachhingen  iiber  Lahmungszustanda  der  untem  Extremitaten 
und  deren  Behandlung.  Stuttgart,  1840.  And  Ueber  spinale  Kinderlahmung. 
2  Aufl.,  1860. 

^  Barthez  et  Eilliet.  Traitd,  clinique  et  pratique,  des  maladies  de  I'enfance. 
Paris,  1863.    Tome  IL,  p.  335. 

*  Duchenne.  Gazette  hebdom.,  1845 ;  et  Traits  de  I'electrisation  localisee.  1'^ 
edit.,  1855. 

*  Duchenne  fils.  De  la  paralysie  atrophique  graisseuse  de  I'enfance,  Paris,  1864  ; 
et  Arch,  g^n^r.  de  m^d..  Tome  II.,  1864,  pp.  28,  184,  441. 


864  SYSTEM  DISEASES  OF  THE 

and  that  of  Laborde^  — both  of  which  are  very  important  on  account  of  the 
many  clinical  facts  contained  in  them.  Dr.  Barlow,^  of  Manchester,  pub- 
lished the  most  important  monograph  on  this  disease  which  has  appeared 
in  this  country,  while  Seeligmiiller*  has  recently  made  two  important  con- 
tributions to  the  subject.  The  first  cases  of  the  spinal  atrophic  paralysis 
of  adults  was  reported  by  Meyer  ;*  in  these  cases  paralysis  of  the  extremities, 
with  flaccidity,  wasting,  and  loss  of  faradic  contractility  in  the  muscles,  super- 
vened suddenly  in  the  patients,  who  were  twins,  aged  eighteen  years,  after 
an  attack  of  measles.  Cases  of  the  disease  were  subsequently  reported  by 
Kussmaul,^  Cuming,^  and  Hallopeau,^  but  the  true  nature  of  the  disease 
was  not  recognised  until  Duchenne^  in  1872  pointed  out  its  identity  with 
the  atrophic  spinal  paralysis  of  infants.  Since  that  time  cases  of  the 
disease  have  been  reported  by  Vulpian,^  Gombault,^"  Frey,^^  Bernhardt,^^ 
Seguin,^^  Charcot,"  Erb,^^  Lemoine,^^  Hermann,"  Weisz,^^  Schultze,^^  Leyden,^ 
Althaus,^^  Stm-ges,^^  Sturge,^^  myself,'^*  and  others.     A  case  of  extensive 

'  Laborde.    De  la  paralysie  dite  essentialle  de  I'enfance.    These,  Paris,  1864. 

^  Barlow  (W.  H.)-     On  regressive  paralysis.     1878. 

3  Seeligmuller.  "Spinale  Kinderlahmmig."  Gerhardt's  Handb.  der  Kinder- 
krankheiten,  Bd.  V.,  1881,  p.  1 ;  und  E,eal-Encyclopadie.  Herausg.  von  A.  Eulen- 
burg,  Bd.  VII.,  1881,  p.  375. 

*  See  Meyer  (M.).  Die  electricitat  und  ihre  anwendung  auf  practische  Medicin. 
3e  Aufl.,  Berl.,  1868,  p.  209. 

*  Kussmaul  und  Maier.  "Periarteritis  nodosa."  Deutsches  Arch.  f.  klin.  Med., 
Bd.  I.,  1866,  p.  506. 

'  Cuming.  "  Case  of  extensive  paralysis  from  morbid  condition  of  the  spinal 
cord,  probably  congestion."  Dublin  Quarterly  Journal  of  Medical  Science,  May, 
1869,  p.  471. 

''  Hallopeau.  "  Des  myelites  chroniques  dififuses."  Arch.  g^n.  de  m^d.,  Vol.  I., 
1872,  p.  70. 

8  Duchenne.    L'electrisation  localisde.    3™e  Edit.,  1872,  p.  437, 

'  Vulpian.  "  Cas  d'atrophie  musculaire  graisseuse."  Arch,  de  Physiol., 
Tome  III.,  1870,  p.  499. 

» 0  Gombault.  "Note  sur  un  cas  de  paralysie  spinale  de I'adulte,  suivi  d'autopsie." 
Arch,  de  Physiologie,  1873,  p.  80. 

11  Frey  (A.).  "Ueber  temporare  Lahmungen  Erwachsener,  die  den  temporaren 
Spinallahmungen  der  Kinder  analog  sind  und  von  Myelitis  der  Vorderhorner 
auszugehen  scheinen."    Berl.  klin.  Wochenschr.,  1874,  pp.  3,  13,  28. 

1 '^  Bernhardt.  "Ueber  eine  der  spinalen  Kinderlahmungen  ahuliche  Affection 
Erwachsener."    Arch,  fur  Psychiat.,  Bd.  IV.,  1874,  p.  370. 

'^Seguin.     Spinal  paralysis  of  the  adult.    New  York,  1874. 

'*  Charcot.  Le§ons  sur  les  maladies  du  systeme  nerveux.  Tome  II.,  2™e  Edit., 
1877,  p.  170. 

^*Erb  (W.).  "Ueber  Acute  Spinallahmung  bei  Erwachsenen."  Arch,  fiir 
Psychiat.,  Bd.  V.,  1875,  p.  767. 

' '  Lemoine.     "  Paralysie  spinale  de  I'adulte  guerison."    Lyon  Medical,  1875. 

'^  Hermann  (J.).     De  la  paralysie  infantile  chez  I'adulte.     These  de  Paris,  1876. 

1 8  Weisz.  Ein  Fall  von  acute  SpinaUahmung  bei  Erwachsenen.  Diss.  Breslau, 
1875. 

' "  Schultze  (F.).    Virchow's  Archiv.    Bd.  LXVIIL,  1876,  p.  140. 

*°  Leyden.     Klinik  der  Riickenmarkskrankheiten.     Bd.  II.,  1875,  p.  198. 

2  1  Althaus  (J.).     On  infantile  paralysis.    Lond.,  1878.    p.  27. 

"  Sturges.    The  Lancet.     Vol.  I.,  1879,  pp.  11  and  627. 

''^Sturge  (W.  A.).  "Three  cases  of  acute  anterior  poliomyelitis."  British 
Medical  Journal,  Vol.  I.,  1877,  pp.  849  and  888. 

**  Eoss  (J.).    The  Practitioner.    August,  1881.    p.  116. 


SPINAL  CORD   AND  MEDULLA  OBLONGATA.  865 

muscular  atrophy  is  described  by  Dr.  Glynn  ^  under  the  title  of  adult 
spinal  paralysis,  but  from  the  profound  sensory  disorders  which  were 
present  it  is  much  more  likely  to  have  been  an  example  of  acute  multiple 
neuritis.  Dr.  Miiller^  has  recently  collected  and  analysed  all  the  pub- 
lished cases  of  atrophic  spinal  paralysis  in  the  adult  frorn  the  time  of 
Duchenne  to  the  present  day. 

§  389.  Etiology. — The  most  remarkable  feature  with  respect 
to  the  etiology  of  this  paralysis  is  the  strong  predisposition  to 
the  affection  manifested  by  the  age  of  childhood.  In  thirty-two 
out  of  forty-four  cases  observed  by  Dr.  West,  the  disease  came 
on  between  the  age  of  six  months  and  three  years ;  while,  if  we 
analyse  the  cases  collected  by  Heine,  Duchenne  the  younger, 
and  those  observed  by  Barlow,  more  than  three-fourths  (154  out 
of  205)  of  all  the  cases  occurred  between  the  ages  of  six  months 
and  two  years.  But  Duchenne  reports  a  case  in  a  child  twelve 
days  old,  and  another  in  a  child  one  month  old,  while  essentially 
the  same  disease  occurs  in  the  adult. 

Neither  sex  nor  hereditary  predisposition  appears  to  exercise 
any  influence  in  producing  the  disease,  and  it  is  even  asserted 
by  Heine  that  the  healthiest  and  most  robust  children  are 
attacked  by  preference. 

The  disease  appears  to  be  most  common  during  the  summer 
months;  thus,  out  of  fifty-three  cases  in  which  the  date  of 
attack  could  be  fixed  with  accuracy  by  Dr.  Barlow,^  twenty- 
seven  occurred  in  the  months  of  July  and  August.  Of  149 
cases  collected  by  Dr.  Wharton  Sinkler,*  six  occurred  in  January, 
one  in  February,  eleven  in  April,  six  in  May,  eighteen  in  June, 
thirty-four  in  July,  forty-three  in  August,  nine  in  September, 
six  in  October,  seven  in  November,  and  two  in  December. 

The  exciting  causes  of  the  affection  are  equally  obscure, 
and  it  often  occurs  in  the  midst  of  robust  health.  Of  all  the 
alleged  causes,  difficult  or  even  normal  dentition  is  the  one 
most  frequently  assigned;   and  it  is  probable  that   too  much 

'  Glj'nn  (T.  E,.).  "Clinical  lecture  on  a  case  of  acute  myelitis,  and  a  case  of 
adult  spinal  paralysis."    The  Lancet,  Vol.  II.,  1878,  pp.  394  and  429. 

*  Miiller  (Franz).  Die  acute  atrophische  Spinallahraung  der  Erwachsenen. 
Stuttgart,  1880.  See  also  Rank  (G.).  "  Zur  Lehre  der  Poliomyelitis  anterior 
acuta  adultorum."    Deutsches  Arch.  f.  klin.  Med.,  Bd.  XXVII.,  1880,  p.  1J9. 

^  Barlow.     On  regressive  paralysis.     1878.     p.  4. 

*  Sinkler  (Wharton).  "  Palsies  of  chilrlren."  American  Journal  of  Medical 
Science,  April,  1875,  p.  353. 

VOL.  I.  DDD 


866  SYSTEM  DISEASES   OF  THE 

rather  than  too  little  importance  has  been  attributed  to  this 
process  in  the  production  of  the  affection.  Injuries  of  various 
kinds  are  often  assigned  as  causes  of  the  disease,  and  nurses  are 
frequently  blamed  unjustly  by  parents,  who,  unable  to  believe 
that  such  a  striking  phenomenon  as  paralysis  can  occur  suddenly 
without  appreciable  cause,  imagine  that  the  child  has  been  lamed 
by  a  fall  through  the  carelessness  of  its  attendant. 

Exposure  to  cold,  more  especially  when  the  body  is  overheated, 
appears  to  have  immediately  preceded  the  paralysis  in  a  consider- 
able number  of  cases  ;  and  the  affection  often  occurs  in  children, 
and  occasionally  in  the  adult,  during  the  progress  or  soon  after 
an  attack  of  measles,  scarlatina,  smallpox,  typhus,  and  other 
acute  affections. 

§  390.  Sym/ptoms. — Although  this  disease  is  essentially  the 
same  in  children  and  in  adults,  yet  the  symptoms  in  each  differ 
so  much  as  to  demand  separate  description.  The  disease  as  it 
occurs  in  children  will  be  first  described. 

(a)  Infantile  Spinal  Paralysis. 

It  will  conduce  to  clearness  of  description  if,  like  Laborde,^  we 
divide  the  clinical  history  of  this  affection  into  four  periods  :  (1) 
Invasion;  (2)  Remission;  (3)  Regression  of  paralytic  phenomena; 
(4)  Atrophy  and  deformities.  It  must,  however,  be  remembered 
that  these  periods  overlap,  instead  of  being  distinctly  separated 
from  each  other,  and  that  this  subdivision  is  merely  adopted  for 
the  sake  of  convenience. 

(1)  Period  of  Invasion. — The  disease  is  commonly  ushered 
in  by  a  more  or  less  intense  fever,  which  is  often  preceded  by 
general  malaise,  pain  in  the  head,  mental  irritability,  fretfulness, 
and  startings  of  the  limbs.  The  fever  is  as  a  rule  of  short 
duration,  lasting  only  from  one  to  two  days ;  in  some  cases  it 
passes  off  in  a  few  hours,  while  in  other  cases  it  may  continue 
from  six  to  fourteen  days,  or  even  longer.  As  the  fever  increases 
the  cerebral  symptoms  become  more  pronounced,  confusion  of 
ideas  and  slight  somnolency  are  observed,  and  the  child  may 
become  unconscious,  or  delirium  of  varying  degrees  of  intensity 
may  supervene. 

'  Laborde  (J.  V.).     De  la  paralysie  de  I'enfance,     Paris,  18C4.    p.  1. 


SPINAL  CORD  AND  MEDULLA   OBLONGATA.  867 

The  disease  is  not  unfrequently  ushered  in  by  convulsions,  these 
having  been  met  with  in  thirty  cases  out  of  seventy  collected  by 
Duchenne.^  Sometimes  the  paralysis  occurs  after  a  single  con- 
vulsion of  short  duration,  while  at  other  times  they  are  repeated 
many  times  at  variable  intervals  before  the  paralysis  is  definitely 
declared.  The  convulsions,  according  to  Laborde,^  often  assume 
the  tonic  form,  the  spasms,  as  a  rule,  being  restricted  to  the 
extremities,  and  only  extending  on  rare  occasions  to  the  face, 
and  he  believes  that  even  in  these  latter  cases  the  attacks  are 
unaccompanied  by  any  other  cerebral  symptoms.  But  in  one  of 
the  cases  quoted  by  Laborde^  in  support  of  this  opinion  the  con- 
vulsion was  accompanied  by  unconsciousness,  so  that  there  are 
not  sufficient  grounds  for  believing  that  these  attacks  differ  in 
any  way  from  ordinary  eclamptic  attacks  so  common  in  children. 
In  the  cases  ushered  in  by  convulsions  fever  is  often  not  men- 
tioned as  having  been  present,  but,  as  Laborde  suggests,  it  is 
probable  that  the  convulsions  assume  such  paramount  proportions 
in  the  minds  of  the  attendants  that  minor  symptoms  are  not 
observed.  In  some  few  cases  all  general  symptoms  are  absent ; 
the  child  is  put  to  bed  apparently  in  good  health  and  is  found 
paralysed  in  the  morning.  In  most  of  these  cases  the  paralysis 
is  limited  to  a  portion  of  a  limb,  indicating  that  the  primary 
lesion  is  circumscribed,  whilst  it  is  possible  that  transitory  fever 
and  other  general  symptoms  may  have  been  present  in  numerous 
cases  in  which  they  have  been  overlooked  owing  to  the  defective 
observation  of  parents. 

(2)  Period  of  Remission. — ^The  initial  symptoms  subside  in  a 
few  days  and  the  general  health  improves,  but  when  the  child  is 
taken  out  of  bed  to  be  bathed,  or  for  some  other  purpose,  it  is 
observed  for  the  first  time  that  one  or  all  the  limbs  hang  down 
relaxed  and  powerless.  The  paralysis  is  as  a  rule  developed  with 
great  rapidity,  but  probably  never  with  the  instantaneousness  of 
that  caused  by  cerebral  haemorrhage;  it  creeps  on  somewhat 
gradually  during  several  hours,  half  a  day,  or  a  night,  before 
attaining  its  acme,  and  in  a  few  cases  it  spreads  still  more  slowly, 
and  does  not  reach  its  maximum  for  several  days.*      In  other 

1  Duchenne  (fils).    Arch,  g^n^r.  de  mki.    VoL  IL,  1864,  p.  37. 

*  Laborde.     Op.  cit.,  p.  14.  'Laborde.     Op.  cit.,  p.  12. 

*  Duchenne.    De  r^lectrisation  localis^e.    3rd  Edit.,  1872,  p.  396. 


868  SYSTEM  DISEASES  OF  THE 

cases  two  or  more  attacks  of  paralysis  succeed  one  another ;  at 
the  first  one  limb  is  affected,  and  this  is  followed  by  improve- 
ment, but  the  child  relapses  in  a  few  days  into  a  feverish  state, 
when  another  limb  is  found  paralysed.^  Still  more  remarkable 
cases  are  recorded  by  Laborde,  in  which  the  paralysis  did  not 
become  permanently  established  until  the  third  attack.^ 

But  notwithstanding  slight  variations,  one  of  the  most 
characteristic  features  of  this  affection  is  that  the  paralysis 
reaches  its  maximum  of  extent  and  intensity  within  a  com- 
paratively brief  space  of  time  from  the  onset.  The  paralysis 
possesses  no  progressive  character ;  it  recedes  but  does  not 
advance  further. 

The  distribution  of  the  paralysis  is  exceedingly  variable.  It 
is  frequently  general,  involving  the  muscles  of  the  four  extremi- 
ties, as  well  as  a  great  part  of  the  muscles  of  the  trunk,  especially 
those  of  the  vertebral  column,  and  sometimes  those  of  the 
neck.  It  also  frequently  assumes  the  paraplegic  form  ;  but  the 
upper  extremities  are  seldom  exclusively  affected.  The  disease 
occasionally  presents  itself  in  the  form  of  a  hemiplegia,  and  in 
these  cases  the  side  of  the  neck,  of  the  face,  and  of  the  tongue^ 
may  be  implicated  at  first  and  may  on  rare  occasions  remain 
permanently  paralysed.*  Out  of  sixty-two  cases  collected  by 
Duchenne  fils,^  the  distribution  of  the  paralysis  was  general  in 
five,  paraplegic  in  nine,  hemiplegic  in  one,  and  crossed  in  two, 
the  right  upper  and  the  left  lower  extremity  being  affected.  In 
twenty-five  cases  the  right  lower  and  in  seven  the  left  lower 
limb  was  affected  ;  in  ten  cases  the  paralysis  was  limited  to  the 
right  or  left  upper  extremity;  in  two  cases  there  was  right  lateral  -^i  "J 
paralysis  of  the  upper  extremity;  and  in  one  case  the  paralysis 
was  restricted  to  the  muscles  of  the  trunk  and  abdomen. 

The  sensibility  is  almost  entirely  unaffected  throughout  the 
whole  progress  of  the  disease.  At  the  outset  of  the  affection 
patients  may  complain   of  pains  and  parsesthesise,  but  these 

'  Althaus  (J.).  On  infantile  paralysis  and  some  allied  diseases  of  the  spinal  cord. 
Lond.,  1878.    p.  12. 

'  Laborde.     Op.  cit.,  p.  8. 

^  Barlow.     Op.  cit.,  pp.  7  and  15. 

*  Buzzard  (T.).  Clinical  lectures  on  diseases  of  the  nervous  system.  Lond., 
1882.    p.  70. 

*  Duchenne  (fils).     Arch,  g^n^r.  de  m^d.    Tome  II.,  1864,  p.  38. 


SPINAL   CORD   AND  MEDULLA  OBLONGATA.  869 

symptoms  are  of  short  duration.  A  certain  degree  of  cutaneous 
hyperesthesia,  or  rather  hyperalgesia,  has  been  described  as 
being  present  during  the  febrile  stage,  but  the  tenderness  to 
touch  described  may  have  been  due  to  affections  of  deeper 
structures,  such  as  rheumatic  inflammation  of  joints. 

Reflex  action  is  completely  abolished  in  all  the  muscles  which 
are  severely  attacked,  and  it  is  much  lowered  or  temporarily 
extinguished  in  those  muscles  that  are  only  slightly  affected. 
The  tendon-reactions  are  also  absent  in  the  paralysed  muscles. 

The  functions  of  the  bladder  and  rectum  are  rarely  affected. 
During  the  first  days,  however,  there  may  be  retention  of  urine, 
but  more  frequently  there  is  incontinence,  and  the  stools  may  be 
passed  involuntarily.  In  young  children  a  slight  weakness  of 
the  bladder  with  occasional  incontinence  may  remain  for  some 
time,  but  as  a  rule  all  disturbances  of  the  bladder  and  rectum 
disappear  in  from  three  to  eight  days  from  the  onset  of  the 
disease. 

(3)  Period  of  Regression. — After  a  certain  time,  which  varies 
from  a  few  days  to  a  few  weeks,  a  gradual  improvement  of  the 
paralysis  takes  place.  This  improvement  may  affect  a  greater 
or  smaller  number  of  the  muscles  involved,  and  some  authors 
think  that  all  the  paralysed  muscles  may  completely  recover. 
The  cases  in  which  complete  recovery  takes  place  have  been 
called  temporary  spinal  paralysis}  Dr.  Edge,^  of  Manchester, 
reports  the  case  of  a  boy,  aged  ten  years,  which  appears  to  have 
belonged  to  this  category.  The  muscles  of  both  extremities  as 
well  as  those  of  the  back  were  paralysed.  The  affected  muscles 
were  slightly  atrophied,  and  their  faradic  contractility  was 
diminished,  there  were  no  bed-sores,  and  no  disturbances  in  the 
functions  of  the  bladder  or  rectum,  but  there  was  transitory 
impairment  of  cutaneous  sensibility  in  the  lower  extremities. 
Recovery  was  complete  in  four  weeks  from  the  commencement 
of  the  attack. 

As  a  rule,  however,  there  is  only  complete  restitution  of  some 
of  the  muscles,  while  the  rest  remain  permanently  paralysed. 
The  mode  in  which  the  paralysis  recedes  is  peculiar.     In  six 

*  Kennedy.     I^ublin  Medical  Press,  26  Sept.,  1844.     The  Dublin  Quarterly 
Journal  of  Medical  Science,  Vol.  IX.,  1850,  p.  85;  and  Vol.  XXXII.,  1861,  p.  277. 
■"  Edge.    The  British  Medical  JournaL    Vol.  II.,  1880,  p.  169. 


870  SYSTEM  DISEASES   OF  THE 

cases  of  generalised  paralysis,  which  Laborde  had  the  opportunity 
of  observing  accurately  from  the  commencement  of  the  attack, 
the  paralysis  in  the  upper  half  of  the  body  began  to  improve 
between  the  third  to  the  fifteenth  day  from  the  commencement ; 
it  disappeared  rapidly  from  the  neck,  upper  extremities,  and 
trunk,  and  became  restricted  to  the  lower  extremities.  This 
improvement  Laborde  calls  the  period  o^  first  ^'ecj'ressioTi,  inasmuch 
as  it  is  followed  after  a  variable  interval  of  time  by  a  second 
period  of  amendment  which  he  calls  the  second  regression. 
During  the  second  regression  there  is  a  gradual  improvement  of 
the  paralysis  in  both  lower  extremities,  and  the  muscles  of  one 
of  them  may  be  completely  restored  to  full  power;  but  the 
paralysis  becomes  permanently  established  in  one  or  more  groups 
of  the  muscles  of  the  other  lower  extremity,  the  anterior  and 
external  group  being  those  most  frequently  left  paralysed.  But 
although  the  improvement  usually  takes  place  from  above  down- 
wards, it  sometimes  occurs  in  the  reverse  order,  and  then  the 
paralysis  becomes  permanently  localised  in  a  superior  extremity; 
and  in  rare  cases  it  becomes  localised  in  the  muscles  of  the  trunk 
or  neck.  In  the  case  of  a  child  two  years  of  age,  under  the  care 
of  Dr.  Simon  at  the  Southern  Hospital,  and  which  I  had  an 
opportunity  of  seeing,  the  muscles  of  the  neck  alone  remained 
paralysed,  and  all  of  these  were  completely  paralysed  and 
atrophied. 

The  chief  facts  which  concern  us  in  this  affection  are  that  the 
paralysis  reaches  its  maximum  of  extent  and  intensity  at  once ; 
that  in  all  cases,  without  exception,  improvement  occurs  in  some 
of  the  paralysed  muscles  ;  that  the  improvement  proceeds  most 
actively  during  the  first  four  to  eight  weeks,  and  subsequently 
at  a  much  slower  rate  ;  and  that  this  improvement  may  continue 
for  from  six  to  nine  months,  and  under  appropriate  treatment 
may  go  on  for  one  or  two  years  from  the  commencement  of  the 
attack. 

(4)  Period  of  Atrophy  and  Deformities. — All  muscles,  in 
which  motor  power  is  not  soon  restored,  become  the  subjects  of 
a  rayidly  progressive  atrophy;  and  even  the  muscles  which  are 
but  slightly  affected  emaciate  to  some  extent,  but  soon  recover 
on  the  restoration  of  voluntary  power. 

The  atrophy  usually  begios  in  the  first  week  of  the  disease, 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  871 

and  it  is  generally  well  marked  in  the  course  of  a  few  weeks  in 
the  muscles  which  are  severely  affected.  The  muscles  become 
more  and  more  flaccid  and  attenuated,  and  after  a  time  may 
disappear  so  completely  that  the  skin  seems  to  lie  immediately 
upon  the  bone.  But  the  extent  of  the  atrophy  of  the  muscular 
substance  is  not  always  exactly  measured  by  the  loss  of  bulk  of 
the  muscle,  inasmuch  as  the  amount  of  atrophy  is  frequently 
masked  by  the  accumulation  of  fat  in  the  connective  tissue.  At 
times,  indeed,  the  volume  of  the  muscle  appears  to  be  increased, 
owing  to  fatty  accumulation  giving  rise  to  the  condition  which 
Duchenne  has  called  pseudo-hypertrophy,  but  in  these  cases 
advanced  atrophy  can  be  readily  recognised  by  the  extreme 
flaccidity  and  doughy  feeling  of  the  affected  muscles  when  com- 
pared with  the  healthy. 

The  condition  of  the  electrical  irritability  of  the  motor  nerves 
and  muscles  deserves  special  attention.  Duchenne  was  the  first 
to  use  the  faradic  current  as  a  test  of  the  degree  of  alteration  in 
the  muscles.  He  found  that  the  faradic  irritability  of  both 
nerves  and  muscles  begins  to  sink  quickly  in  those  which  are 
severely  affected ;  that  it  was  materially  diminished  at  the  end 
of  three  to  five  days ;  and  that  it  was  entirely  abolished  by  the 
seventh  day  or  during  the  course  of  the  second  week.  He  also 
laid  down  a  rule  which  has  been  confirmed  by  all  subsequent 
observers,  and  the  practical  importance  of  which  it  is  difficult  to 
exaggerate — viz.,  that  all  the  paralysed  muscles  in  which  the 
faradic  irritability  is  only  more  or  less  diminished,  but  not 
completely  lost,  during  the  course  of  the  second  week,  do  not 
remain  permanently  paralysed,  the  restoration  being  the  more 
prompt  and  complete  the  less  their  faradic  irritability  has  been 
diminished. 

The  galvanic  irritability  was  first  investigated  by  Solomon, 
who  showed  that  the  course  of  the  alteration  resembled  that  of 
severe  traumatic  paralysis.  There  is  rapid  loss  of  galvanic  irrita- 
bility in  the  nerves  during  the  first  two  weeks  of  the  paralysis, 
and  the  irritability  of  the  muscles  manifests  the  quantitative  and 
qualitative  changes  which  characterises  the  reaction  of  degenera- 
tion. During  the  first  weeks  of  the  paralysis  there  is  an  increase 
of  the  galvanic  irritability,  the  reaction  to  anodal  is  stronger 
than  that  to  cathodal  closure,  and  the  contraction  of  the  muscle 


872  SYSTEM  DISEASES   OF   THE 

is  sluggish  and  protracted,  instead  of  being  instantaneous  as  in 
health.  In  the  course  of  two  or  three  months  the  galvanic 
irritability  sinks  again  much  below  the  normal  standard,  but 
retains  the  characteristic  qualitative  alterations,  and  in  the 
course  of  one  or  two  years  from  the  beginning  of  the  disease 
there  is  only  a  trace  of  it  left.  In  the  muscles  that  do  not 
undergo  atrophy,  and  in  those  which  have  regained  their  motor 
power  a  greater  or  lesser  diminution  in  the  faradic  and  galvanic 
irritability  may  be  found,  but  the  reaction  of  degeneration  is 
absent. 

Arrest  of  development  of  the  osseous  system  is  an  important 
symptom  to  which  Duchenne  and  Yolkmann^  have  directed 
special  attention.  The  atrophy  of  the  bones  has  no  necessary 
relation  with  that  of  the  muscles.  The  greater  part  of  the 
muscles  may  indeed  be  lost  in  a  limb,  while  the  bones  are  almost 
entirely  unaffected  ;  and,  conversely,  a  limb  may  be  considerably 
shortened,  while  only  one  or  two  muscles  are  atrophied.  The 
case  of  a  girl,  aged  nine  years,  is  mentioned  by  Volkmann,  who 
had  unilateral  atrophy  of  the  face,  but  apparently  no  trace  of 
paralysis.  The  patient's  mother  stated  that  during  the  first  year 
of  life  one  arm  was  completely  paralysed  after  an  attack  of 
teething  convulsions.  Very  soon  afterwards  it  was  observed 
that  the  growth  of  the  face  was  unsymmetrical.^  This  case  is 
much  more  likely  to  have  been  an  example  of  the  spastic  hemi- 
plegia of  infancy,  and  caused  by  a  cerebral  lesion,  than  an 
instance  of  the  atrophic  paralysis  of  infancy.  The  failure  of 
Volkmann  to  distinguish  between  the  spastic  and  atrophic 
paralysis  of  infancy  renders  his  other  conclusions  less  trustworthy. 

The  paralysed  leg  may  after  some  years  be  found  from  two  to 
six  inches  shorter  than  the  sound  limb ;  and  the  upper  extremity 
may  be  similarly  shortened,  although  not  generally  to  the  same 
degree.  The  long  bones  are  thinner  than  normal ;  they  are 
porous,  friable,  and  yielding ;  their  epiphyses  and  processes 
grow  smaller  and  less  distinct ;  the  paralysed  hand  or  foot  is 
shorter,  narrower,  and  thinner  than  the  sound  one;  and  even  the 
pelvis  may  be  arrested  in  its  development. 

1  Volkmnnn  (R.).  "  Ueber  Kinderlahmung  und  paralytische  Contracturen." 
SammluDg  klinischer  Vortrage,  1870,  p.  1. 

^  Volkmann  (R.).    The  Lancet,    Vol.  I.,  1870,  p.  2G1. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  873 

The  joints  become  deformed  and  unusally  movable.  The 
increased  mobility  of  the  joints  is  caused  partly  by  the  dis- 
appearance of  the  articular  extremities  of  the  bones,  and  partly 
by  relaxation  and  stretching  of  their  ligaments.  The  relaxation 
of  the  latter  is,  indeed,  sometimes  so  great  that  the  patient  can 
dislocate  a  joint  without  experiencing  any  discomfort. 

The  shin  of  the  affected  extremity  becomes  flabby,  its  loss  of 
elasticity  being  manifested  by  long  retention  of  slight  pressure 
marks,  such  as  that  produced  by  the  stocking.  The  surface  of 
the  limb  assumes  a  mottled  or  bluish  colour,  and  it  is  remark- 
ably cold  to  the  touch,  the  reduction  of  temperature  in  old- 
established  cases  being  from  5°  to  12°  F.,^  lower  than  that  of  the 
corresponding  healthy  limb.  The  skin  is  liable  to  be  affected 
with  chilblains,  and  indolent  ulcers  form  on  slight  provocation, 
whilst  the  defective  nutrition  and  great  coldness  of  the  skin  often 
cause  a  slight  diminution  of  cutaneous  sensibility.  The  nutritive 
and  vascular  changes  in  the  affected  extremity  are  accompanied 
by  diminution  in  the  calibre  of  the  arteries.^ 

Deformities. — The  various  deformities  which  occur  in  the 
affected  limbs  in  infantile  spinal  paralysis  give  to  the  disease 
some  of  its  most  characteristic  features.  Various  opinions  have 
been  held  by  different  authors  with  respect  to  the  mechanism 
by  which  these  deformities  are  produced.  Some  pathologists 
believe  that  the  healthy  muscles  are  always  maintained  in  a 
condition  of  moderate  contraction,  constituting  the  normal  tonus 
of  the  muscles,  and  when  this  tonus  is  destroyed  by  paralysis  in 
a  certain  group  of  muscles,  the  predominant  action  of  their 
healthy  antagonists  produces  a  deformity.  Volkmann,^  however, 
denies  the  existence  of  muscular  tonus,  and  thinks  that  the 
deformity  is  mainly  produced  by  the  weight  of  the  limb  itself. 
He  points  out  that  in  paralytic  deformities  of  the  lower  extremi- 
ties, the  position  generally  assumed  by  the  foot  is  only  a  high 
degree  of  that  which  it  takes  when  unsupported  and  left  free 
from  the  action  of  the  muscles.     The  weight  of  the  limb  and 

1  Heine.  Ueber  Spinal  Kinderlahmungen.  2  Aufl.,  1860,  p.  15  et  seq.  See  also 
Keynolds  (J.  Russell).  Clinical  lecture  on  paralysis,  with  wasting  of  muscles, 
especially  in  children.     The  Lancet,  Vol.  I.,  1868,  p.  36. 

*  Charcot  f,T.  M.).  Le5ons  sur  les  maladies  les  systeme  nerveux.  2nd  Edit., 
Tome  IL,  1877,  p.  157. 

^  Volkmann  (R.).  "Clinical  lecture  on  infantile  paralysis  and  paralytic  con- 
tractions."   The  Lancet,  Vol.  I.,  1870,  p.  333. 


874  SYSTEM   DISEASES   OF   THE 

the  direction  in  which  mechanical  forces  act  upon  it  during  loco- 
motion are  undoubtedly  important  causes  of  deformities,  but  two 
other  co-operating  factors  may  be  mentioned.  The  paralysed 
muscles  permit  the  limb  frequently  to  assume  a  position  in  which 
the  ends  of  their  healthy  antagonists  are  more  or  less  perma- 
nently approximated,  and  the  latter  consequently  undergo  adapted 
atrophy,^  and  become  permanently  shortened.  The  second  factor 
consists  of  an  affection  of  the  paralysed  muscles  themselves.  The 
atrophied  muscles  are  probably  at  times,  like  the  bones,  the  sub- 
jects of  arrested  development;  their  growth  does  not  keep  pace 
with  that  of  the  healthy  muscles  and  of  the  body  generally, 
hence  they  become  permanently  shortened.  Some  have  sup- 
posed that  proliferation  of  the  interstitial  connective  tissue  and 
its  subsequent  retraction  may  occur  in  the  course  of  the  atrophy 
of  the  muscles,  and  thus  lead  to  permanent  shortening  in  them, 
but  this  is  doubtful.  When  the  deformity  is  caused  by  shortening 
of  the  paralysed  muscles,  the  latter  are  found  in  the  concavity 
of  the  distorted  extremity.  But  whatever  may  be  the  mechanism 
by  which  these  deformities  are  produced,  it  would  seem  that, 
disregarding  a  certain  degree  of  inequality  and  disfigurement 
caused  by  the  arrest  of  development  of  the  long  bones,  paralysis 
of  certain  muscles  and  groups  of  muscles,  along  with  relaxation 
of  the  ligaments,  is  the  main  cause  of  the  various  distortions 
observed. 

Some  of  the  muscles  of  one  lower  extremity  suffer  more  fre- 
quently than  others  from  permanent  paralysis ;  and  of  these  the 
antero-external  group  of  the  leg — the  long  extensor  of  the  toes, 
tibialis  anticus,  special  extensor  of  the  great  toe,  and  the  long 
and  short  peronei — are  those  most  commonly  affected.  The 
most  frequent  forms  of  paralytic  talipes  are,  therefore,  as  might 
have  been  expected,  talipes  equinus  and  equino-varus  (Plate  II.,  5). 
When  the  anterior  group  and  the  adductors  of  the  foot  are  affected 
at  the  same  time  talipes  equino-varus  results ;  and  when  the 
muscles  of  the  calf  are  alone  affected  talipes  calcaneus  is  pro- 
duced, but  this  form  is  exceedingly  rare,  and  simple  paralytic 
talipes  varus  is  of  still  rarer  occurrence.  Another  common 
deformity  is   the    "  pes  cavus  "• — "  talus   pied   creux  "    of    the 

1  Adams  (W.).  Club  foot  :  its  causes,  pathology,  and  treatment.  2nd  Edit., 
London,  1873,  p.  87. 


SPINAL   CORD   AND  MEDULLA   OBLONGATA. 


875 


Fig.  189. 


French — in  which  the  sole  is  hollowed  and  the  instep  rendered 
prominent.  Duchenne  thinks  that  it  is  caused  by  a  more  or  less 
complete  paralysis  of  the  muscles  of  the  calf,  along  with  simul- 
taneous contraction  of  the  flexors  of  the  foot,  either  the  long 
flexor  of  the  toes  or  the  long  peroneus.  The  great  laxity  of  the 
ligaments  of  the  foot  allows  the  latter  to  become  bent  upon  itself 
from  the  transverse  tarsal  joint,  where  the  foot  is  unsupported, 
but  when  it  is  placed  upon  the  ground  it  assumes  the  form  of 
"  flat  foot." 

Various  deformities  occur  in  the  inferior  extremity,  according 
to  the  extent  and  localisation  of  the  paralysis.  The  anterior 
and  internal  muscles  of  the  thigh  are  most  usually  affected 
above  the  knee,  and  in  that  case  the  predominant  action  of  the 
flexors  of  the  leg  on  the  thigh  maintains  the  former  in  a 
permanent  condition  of  partial 
flexion  (genu  recurvatum),  the 
leg  being  also  abducted  {Fig. 
189).  The  condition  is  always 
associated  with  talipes  equino- 
varus.  The  annexed  woodcut  is 
from  a  photograph  kindly  taken 
for  me  by  Mr.  Larmuth.  All 
the  muscles  of  both  legs  are 
sometimes  paralysed  so  that  the 
patient  is  compelled  to  walk  on 
his  knees,  dragging  his  small 
thin  legs  after  him.  In  still 
more  aggravated  cases  the  mus- 
cles of  both  legs  and  thighs  are 
permanently  paralysed  so  that 
the  small  flexible  limbs  dangle 
about  like  the  limbs  of  a  doll 
(jambe  de  polichinelle). 

Paralysis  of  the  muscles  of  the 
trunk  does  not  give  rise  in  this 
disease  to  a  true  active  curva- 
ture of  the  vertebral  column,  but 
the  attitudes  imposed  by  other 

^   c         •••  1  Fig.  189  (Larmuth).     Case  of  infantile 

detormities    may   produce    com-  paralysis  (genu  recurmtum). 


876  SYSTEM  DISEASES   OF  THE 

pensatory  curvatures.  Of  the  curvatures  directly  attributable 
to  the  paralysis,  lordosis  is  the  most  frequent  and  most  im- 
portant. Lordosis  is  caused  by  partial  paralysis  of  the  sacro- 
spinal muscles,  and  in  order  to  prevent  the  permanent  bending 
forwards  of  the  body  by  the  predominant  action  of  the  flexors, 
the  patient  voluntarily  throws  the  trunk  backwards,  thus  relieving 
the  weakened  extensors  and  throwing  additional  weight  on  the 
flexors,  so  that  the  balance  between  the  action  of  the  two  sets  of 
muscles  is  re-established.  The  spinal  curvature  which  results 
from  this  action  differs  from  other  forms  of  lordosis,  inasmuch 
as  the  pelvis  is  pushed  forwards  instead  of  backwards,  and  the 
buttocks  become  less  instead  of  more  prominent. 

The  deformities  of  the  upper  extremities  are  much  less  fre- 
quent and  serious  than  those  in  the  lower  extremities.  The 
muscles  of  the  shoulder,  and  particularly  the  deltoid,  are  the 
most  usual  subjects  of  paralysis  and  atrophy  in  the  upper 
extremity.  In  these  cases  the  shoulder  is  flattened,  and  the 
prominence  of  the  deltoid  is  replaced  by  a  more  or  less  deep 
depression  according  to  the  degree  of  atrophy;  the  humerus 
becomes  separated  from  the  glenoid  cavity,  so  that  dislocation 
ma}'-  occur  spontaneously,  or  is  readily  produced ;  the  arm  hangs 
powerless  by  the  side ;  and,  to  use  the  apt  comparison  of  Heine, 
dangles  about  like  the  loose  end  of  a  flail.  In  exceptional  cases 
the  forearm  and  hand  may  undergo  distortion,  but  these  deformi- 
ties are  not  of  sufficient  importance  or  frequency  to  require 
description.  All  the  organic  functions  are  well  performed,  and 
the  patient  may  live  to  extreme  old  age,  as  in  the  case  of  a 
patient  observed  by  Charcot,  who  died  at  the  age  of  seventy, 
carrying  with  him  indelible  traces  of  the  disease  from  which  he 
had  suffered  sixty-five  years  before. 

The  muscles  are  paralysed  in  infantile  spinal  paralysis  in 
groups,  in  accordance  with  their  association  in  action.  Particular 
attention  has  recently  been  directed  to  this  point  by  E.  Remak.* 
In  what  he  calls  "  the  upper-arm  type  "  of  atrophic  paralysis, 
the  supinator  longus  is  involved  along  with  the  deltoid,  brachialis 
anticus,  and  biceps  muscles.  In  what  Remak  calls  "  the  fore- 
arm type  "  of  infantile  paralysis,  as  well  as  in  lead  paralysis,  the 

1  Kemak  (E.).  "  Ueber  die  Localisation  atropHscher  Spinallahmungen  und 
spinaler  Atrophieen."    Arch.  f.  Psychiat.,  Bd.  IX.,  1878-9,  p.  510. 


SPINAL  CORD   AND  MEDULLA  OBLONGATA.  877 

extensor  muscles  of  the  hand  are  paralysed,  while  the  supinator 
longus  is  spared. 

Analogous  facts  have  been  observed  in  the  various  atrophic 
paralyses  of  the  lower  extremities.  Cases  of  infantile  paralysis 
are  recorded  by  E.  Remak  in  which  the  tibialis  anticus  and  all 
the  muscles  supplied  by  the  crural  nerve,  with  the  exception  of 
the  sartorius,  were  paralysed,  and  he  therefore  conjectures  that 
the  spinal  nuclei  of  the  former  and  those  of  the  latter,  with  the 
exception  of  that  of  the  branch  to  the  sartorius,  lie  near  each 
other  in  the  spinal  cord,  and  are  liable  to  be  diseased  at  the  same 
time.  Duchenne  has  proved  that  the  sartorius  is  associated  in 
its  functions,  not  so  much  with  the  quadriceps  and  adductors  as 
with  the  flexors,  inasmuch  as  it  flexes  the  leg  on  the  thigh,  and 
the  thigh  on  the  pelvis,  Bernhardt^  has  compared  the  sartorius 
to  the  supinator  longus,  and  it  appears  also  to  correspond  with 
the  latter  in  having  its  spinal  nucleus  near  that  of  the  flexors, 
and  not  of  the  extensors  with  which  it  is  in  anatomical  relation. 
Cases,  however,  have  not  yet  been  recorded  showing  that  the 
sartorius  is  paralysed  along  with  the  flexors  of  the  leg,  the  ex- 
tensors being  spared,  corresponding  to  what  occurs  with  the 
supinator  longus  in  the  upper-arm  type  of  atrophic  paralysis. 
The  tibialis  anticus  is  also  frequently  spared  in  infantile  paralysis 
when  the  other  anterior  muscles  of  the  leg  are  implicated. 
Remak  has  stated  that  when  lead  paralysis  affects  the  lower  ex- 
tremities the  peroneal  group  are  affected,  but  the  tibialis  anticus 
is  spared,  and  he  has  conjectured  that  the  spinal  nucleus  of  the 
tibialis  anticus  is  on  a  higher  level  than  those  of  the  other 
muscles  of  the  peroneal  region,  but  he  has  recently  recorded 
another  case  which  appears  to  contradict  this  opinion.^ 

(h)  Acute  Spinal  Paralysis  of  Adults. 

Acute  spinal  paralysis  of  adults  is  essentially  the  same  disease 
as  infantile  spinal  paralysis.  The  differences  between  the  two 
affections  result  from  the  facts  that  the  brain  offers  greater 
resistance  in  the  adult  as  compared  with  the  infant  to  the  initial 

'Bernhardt.  "Ueber  periphere  Lahmungen."  Arch.  f.  Psychiat.,  Bd.  VIL, 
1876-7,  p.  593. 

"Remak  (E.).  "  Zur  Localisation  saturniner  Lahmungen  der  Unterextremi- 
taten."    Neurologische  Centralb.,  Bd.  I.,  1882,  p.  149. 


878  SYSTEM  DISEASES  OF  THE 

disturbances;  that  the  organism  is  not  so  disposed  to  fever;  that 
the  growth  of  the  bones  is  already  completed ;  and  that  the 
ligaments  and  joints  are  firm  and  resisting. 

The  disease  begins  in  the  adult  by  pain  in  the  back  and  the 
extremities,  parsesthesise,  such  as  formication  or  numbness,  and 
fever,  which  at  times  is  very  intense.  There  may  be  severe 
headache,  vomiting,  somnolency,  or  even  slight  delirium,  but 
convulsions  have  never  been  observed. 

The  paralysis  is  developed  more  or  less  rapidly,  generally  in 
the  course  of  a  few  hours,  and,  as  in  the  case  of  children,  it  is 
more  or  less  widely  spread,  complete,  and  associated  with  entire 
flaccidity  of  the  paralysed  muscles.  Reflex  action  is  either  much 
lowered  or  abolished  in  the  paralysed  muscles,  but  may  be 
retained  in  those  which  are  only  slightly  affected.  Temporary 
weakness  of  the  bladder  may  be  present  at  first. 

The  initial  general  symptoms  pass  off  in  a  few  days;  soon 
afterwards  the  paralytic  symptoms  begin  to  improve,  and  after 
some  weeks  or  months  restitution  of  motor  power  may  be 
complete.  Frey  has  called  this  variety  temporary  'paralysis, 
corresponding  to  the  form  of  the  same  name  in  children.  That 
complete  recovery  may  take  place,  the  following  case,  which 
has  been  recorded  by  myself,  fully  testifies.  I  am  indebted  to 
Mr.  Blore  for  the  notes  of  the  case,  and  to  my  friend  Dr.  Brown, 
of  Burnley,  who  kindly  sent  the  patient  to  me: — 

Eliza  C ,  aged  twenty-two  years,  unmarried,  entered  the  Manchester 

Royal  Infirmary  under  the  care  of  Dr.  Ross  on  February  19,  1881. 

The  patient's  occupation,  that  of  a  weaver,  has  confined  her  much 
within  doors,  but  she  has  always  enjoyed  good  health,  and  never  suflfered 
from  any  serious  illness.  She  states  that  on  January  8th,  six  weeks  pre- 
vious to  admission,  she  caught  a  chill,  and  for  the  subsequent  twenty-four 
hours  she  suffered  from  headache  of  unusual  severity.  This  was  on  a 
Saturday,  and  on  the  following  Monday  she  felt  quite  well,  and  went  to  her 
work  as  usual.  About  eight  o'clock  on  the  Monday  evening,  however,  she 
was  suddenly  seized  with  a  severe  and  continuous  pain  between  the  shoulders, 
which  extended  laterally  over  both  shoulder  blades.  She  retired  to  bed  and 
soon  slept,  in  spite  of  the  severe  pain  from  which  she  continued  to  suffer. 
On  awaking  in  the  morning  she  found  that  her  left  hand  and  fingers  hung 
useless,  and  the  pain,  although  much  less  severe  than  on  the  previous 
evening,  still  continued,  and  did  not  finally  disappear  until  about  a  week 
from  the  commencement.  The  patient  states  that  she  could  still  bend  the 
forearm  upon  the  arm,  and  she  appears  to  think  that  the  power  of  moving 


SPINAL   CORD   AND   MEDULLA  OBLONGATA.  879 

the  upper  arm  and  bending  the  forearm  at  the  elbow  gradually  diminished, 
and  was  not  quite  lost  mitil  the  end  of  the  first  week. 

Present  Condition. — The  patient  is  rather  tail  and  slender,  of  fair  com- 
plexion, and  somewhat  delicate  appearance ;  but  she  has  always  enjoyed 
good  health,  and  the  internal  organs  are  healthy.  When  she  stands,  her 
left  arm  hangs  helpless  by  her  side.  The  palm  of  the  hand  is  directed 
backwards  and  outwards,  the  upper  arm  being  rotated  inwards,  and  the 
forearm  pronated.  The  fingers  are  slightly  flexed  at  the  metacarpo- 
phalangeal, and  completely  flexed  at  the  phalangeal  joints.  The  thumb  is 
also  flexed  at  the  metacarpo-phalangeal  joint,  and  still  more  strongly 
flexed  at  the  phalangeal  joint,  and  its  point  is  directed  under  the  index, 
and  to  the  side  of  the  middle  finger.  The  patient  cannot  voluntarily 
abduct  the  arm,  or  rotate  it  outwards,  but  she  can  produce  a  backward  and 
forward  movement  of  the  whole  limb,  apparently  by  means  of  the  triceps, 
latissimus  dorsi,  and  pectoral  muscles,  the  deltoid  remaining  quite  flaccid 
during  these  movements.  When  passive  abduction  of  the  arm  is  performed, 
the  patient  can  voluntarily  adduct  the  limb  with  scarcely  diminished  power, 
and  when  passive  outward  rotation  is  produced  she  can  perform  forcible 
inward  rotation.  She  is  quite  unable  to  flex  the  forearm  upon  the  arm, 
but  when  passive  flexion  is  produced  she  can  extend  it  as  powerfully  as  the 
other  arm.  When  the  forearm  is  held  midway  between  pronation  and 
supination,  and  semi-flexed  upon  the  arm,  the  patient  cannot  produce 
further  flexion  of  it,  and  during  voluntary  efforts  at  flexion  the  supinator 
longus  remains  quite  flaccid.  She  is  also  unable  to  supinate  the  forearm, 
but  when  it  is  passively  supinated  pronation  is  powerfully  effected.  When 
the  forearm  is  supported  in  a  horizontal  position,  and  pronated,  the  hand 
drops  at  the  wrist,  and  the  fingers  hang  loose  and  pendulous,  just  as  occurs 
in  the  "wrist  drop"  of  lead  palsy.  The  patient  cannot,  by  voluntary 
effort,  extend  the  hand  at  the  wrist,  the  fingers  at  the  metacarpo-phalangeal 
articulations,  or  the  thumb  at  the  metacaqjo-phalangeal  or  phalangeal  joint. 
When,  however,  the  fingers  are  passively  extended  on  the  metacarpal  bones, 
and  fixed  in  this  position,  the  patient  can  readily  extend  the  second  and 
third  phalanges.  When  the  palm  of  the  hand  is  laid  flat  on  a  table,  the 
patient  can  separate  the  fingers  from  and  approximate  them  to  the  middle 
finger  with  undiminished  power.  Adduction,  flexion,  and  opposition  of  the 
thumb  can  also  be  readily  effected,  while  flexion  of  the  fingers  and  at 
the  wrist  joint  can  be  performed  with  as  much  power  on  the  left  as  the 
right  side.  The  paralysed  arm  is  not  perceptibly  wasted,  but  there  is  some 
degree  of  flattening  of  the  posterior  surface  of  the  left  as  compared  with  the 
corresponding  part  of  the  right  forearm. 

The  faradic  and  galvanic  irritability  to  medium  currents  is  lost  in  the 
circumflex,  musculo-cutaneous,  and  musculo-spiral  nerves,  with  the  excep- 
tion of  the  branch  of  the  latter  supplying  the  triceps  muscle. 

The  deltoid,  supra-spinatus,  infra-spinatus,  teres  minor,  biceps,  coraco- 
brachiahs,  supinator  longus,  and  extensors  of  the  wrist,  fingers,  and  thumb 
do  not  react  to  stronar  faradic  currents.     The  extensor  muscles  of  the  fore- 


880  SYSTEM  DISEASES   OF  THE 

arm  react  more  readily  than  do  the  corresponding  muscles  of  the  healthy 
limb  to  galtanic  cui'rents,  and  the  reaction  to  anadol  closure  is  equal  to 
that  of  cathodal  closure.  The  galvanic  irritability  of  the  supinator  longus, 
coraco-brachialis,  biceps,  deltoid,  infra-spinatus,  teres  minor,  and  supra- 
spinatus  is  only  slightly  in  excess  of  that  of  the  same  muscles  on  the 
opposite  side,  and  cathodal  closing  contraction  is  in  excess  of  anodal  closing 
contraction. 

Every  form  of  cutaneous  sensibility  is  normal  in  the  affected  limb,  with 
the  exception  of  a  small  ai-ea  over  the  metacarpal  bone  of  the  thumb,  which 
the  patient  states  is  numb  ;  but  even  in  this  part  the  sensibility  to  pain, 
touch,  and  temperature  is  found  to  be  normal  on  objective  examination. 

During  a  stay  of  four  weeks  in  the  Infirmary  no  appreciable  change ' 
took  place  in  the  condition  of  the  arm,  and  the  patient  was  sent  to  the 
Convalescent  Hospital  at  Cheadle. 

The  patient  was  again  examined  in  the  middle  of  May,  and  it  was  then 
found  that  the  supra-spinatus,  infra-spinatus,  and  teres  minor  muscles  had 
recovered  motor  power,  and  the  patient  could  now  produce  a  strong  out- 
ward rotation  of  the  arm  by  voluntary  effort.  The  arm  could  also  be 
retracted  and  slightly  abducted,  and  during  this  movement  the  posterior 
third  of  the  deltoid  could  be  felt  contracted.  The  anterior  two-thirds  of  the 
deltoid,  the  biceps,  and  supinator  longus  and  the  extensors  of  the  wrist, 
fingers,  and  thumb  remain  paralysed.  No  opportunity  was  afforded  of 
examining  the  electrical  irritability  of  the  paralysed  muscles,  and  the 
patient  was  discharged. 

June  29 :  The  patient  came  to  the  Infirmary  this  morning,  and  it  is 
now  found  that  considerable  improvement  has  taken  place.  She  can 
abduct  the  left  arm  and  hold  it  out  horizontally,  and  during  this  action 
every  part  of  the  deltoid  is  felt  strongly  contracted.  She  can  flex  the  fore- 
arm on  the  arm  with  considerable  power,  and  on  resistance  being  offered  to 
the  flexure  of  the  forearm  beyond  a  right  angle  the  belly  of  the  supinator 
longus  is  felt  strongly  contracted.  The  patient  can  also  supinate  the 
forearm  with  considerable  force  when  previously  pronated.  The  extensors 
of  the  wrist,  fingers,  and  thumb,  however,  remain  completely  paralysed. 

The  supra-spinatus,  infra-spinatus,  teres  minor,  deltoid,  biceps,  coraco- 
brachiahs,  and  supinator  longus  react  to  an  interrupted  cm-rent  of  medium 
strength,  and  also  to  a  galvanic  current,  a  minimum  contraction  being 
obtained  on  cathodal  closure  with  twenty  cells  Leclanche,  and  on  anodal 
closure  with  thirty  cells.  The  radial  and  vdnar  extensors,  the  common 
extensors  of  the  fingers,  and  the  extensors  of  the  thumb,  index,  and  little 
fingers  do  not  react  to  a  strong  faradic  current,  but  these  muscles  give  a 
minimum  contraction  on  cathodal  closure  with  ten  cells  and  on  anodal 
closure  with  five  cells. 

It  was  now  supposed  that  the  extensors  would  remain  permanently 
paralysed,  and  Messrs.  Wood,  surgical  instrument  makers,  of  this  city, 
constructed,  under  my  directions,  a  kind  of  splint,  by  means  of  which  the 
hand  was  maintained  fixed  in  a  line  with  the  forearm,  while  the  action  of 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  881 

tlie  paralysed  extensor  muscles  was  supplied  by  means  of  india-rubber 
bands.  The  instrument  was  similar  to  that  constructed  by  Duchenne, 
only  that  the  spiral  wires  used  by  him  were  replaced  by  india-rubber  bands. 
The  patient  now  returned  to  her  home  with  a  very  useful  hand. 

Towards  the  end  of  December  I  paid  a  visit  to  Dr.  Brown,  and  he 
kindly  arranged  for  me  to  see  the  patient.  To  my  great  surprise  I  found 
that  she  had  discarded  the  use  of  the  instrument  two  months  (ten  months 
from  the  commencement  of  the  disease)  previously,  and  that  she  had  com- 
pletely recovered  all  the  movements  of  the  hand  and  fingers.  From  an 
ordinary  examination  I  was  unable  to  detect  the  slightest  difference 
between  the  motor  power  of  the  left  and  right  hands,  and  the  patient 
considered  that  she  had  made  a  complete  recovery,  but  I  had  no  oppor- 
tunity of  testing  the  electric  reactions  of  the  muscles. 

Generally,  however,  there  is  only  partial  restoration  of  motor 
power,  and  some  of  the  muscles  remain  permanently  paralysed. 
The  latter  muscles  undergo  rapidly  progressive  atrophy,  as  in 
the  case  of  children,  and  afford  the  usual  evidences  of  the 
reaction  of  degeneration.  The  skin  becomes  lax  and  withered, 
and  the  extremities  cold  and  cyanotic. 

In  infants  paralysis  of  one  extremity  is  most  commonly  met 
with,  but  in  adults,  according  to  Muller,^  paralysis  of  the  four 
extremities,  or  of  both  the  lower  extremities,  is  the  most  fre- 
quent. Out  of  forty-seven  cases  collected  by  him  the  paralysis 
was  general  in  twenty-two,  and  paraplegia  was  present  in  eleven 
cases.  In  three  cases  both  upper  extremities  were  paralysed, 
in  three  there  was  hemiplegia,  and  in  one  the  paralysis  was 
crossed.  The  right  upper  extremity  was  paralysed  in  one,  the 
left  in  two,  the  right  inferior  in  two,  and  the  left  inferior  limb 
in  one  case. 

The  sensory  disturbances  which  may  have  existed  at  the 
beginning  soon  subside,  and  the  sensibility  becomes  normal, 
the  sexual  functions  are  throughout  unaffected,  there  are  no 
bed  -sores,  and  the  general  health  is  good. 

Paralytic  contractions  supervene  with  their  resulting  deformi- 
ties, but  the  latter  never  attain  the  same  degree  as  in  children, 
because  the  joints  and  ligaments  are  firmer  in  the  adult,  and  the 
long  bones  of  the  extremities  have  attained  their  full  develop- 
ment 

'  Miiller  (Franz).  Du  acute  atrophische  spinallahmung  der  Erwachsenen. 
Stuttgart,  1880.  p.  64.  See  also  Rank  (G.).  Deutsches  Arch.  f.  klinmed.,  Bd. 
XXVII.,  1880-1,  p.  129, 

VOL.  I.  EEE 


882 


SYSTEM  DISEASES   OF  THE 


§  391.  Course,  Duration,  and  Terminations. — The  ordinary- 
course  of  the  disease  is  generally  the  same  as  that  already- 
described.  Cases  of  this  disease  divide  themselves  into  t-wo 
classes :  (1)  Those  in  -which  complete  recovery  takes  place,  and 
(2)  those  in  which  the  recovery  remains  incomplete.  In  the 
first  variety  complete  restoration  of  all  the  muscles  takes  place 
in  the  course  of  a  few  weeks  or  months.  In  the  second  variety 
some  of  the  muscles  remain  permanently  paralysed,  and  atrophy, 
with  secondary  deformities,  results.  The  paralysis  does  not 
greatly  interfere  with  the  general  well-being  of  the  patient,  and 
does  not  appear  to  have  any  influence  in  accelerating  death, 
at  least  directly,  although  the  resulting  deformities  may  do  so 
indirectly.  Persons  who  have  had  an  attack  of  spinal  paralysis 
do  not  indeed  appear  to  be  more  liable  in  later  life  to  other 
affections  of  the  spinal  cord  than  healthy  persons  generally. 

§  392.  Morbid  Anatomy. — The  main  pathological  changes 
which  have  been  found  in  infantile  paralysis  may  be  subdivided 
into  those  which  have  been  met  with  (1)  in  the  muscles,  and  (2) 


Fig.  190  (Young).  Muscular  Fibres  from  a  Case  of  advanced  Infantile  Paralysis, 
withdrawn  by  Leech's  trocar. — a.  Muscular  fibres  presenting  a  more  or  less 
healthy  appearance  ;  6,  muscular  fibres,  somewhat  atrophied,  and  with  granular 
contents ;  c,  muscular  fibres  greatly  atrophied,  but  presenting  faint  traces  of 
transverse  striation,  and  having  their  surfaces  thickly  studded  with  nuclei. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  883 

ia  the  nervous  system.  Changes  have  been  found  in  the  ten- 
dons and  bones,  skin  and  joints,  but  these  are  of  subordinate 
importance. 

(1)  Morbid  Changes  in  the  Paralysed  Muscles. — It  is  quite 
unnecessary  to  describe  at  length  the  changes  which  occur  in  the 
paralysed  muscles,  inasmuch  as  they  have  already  been  described 
in  the  first  part  of  this  work  (§  112),  along  with  the  other 
trophoneuroses.  By  the  kindness  of  Dr.  Leech,  I  am,  however, 
enabled  to  show  in  Fig.  190  the  condition  of  the  muscular  fibres 
in  advanced  atrophy  when  a  portion  of  the  muscle  is  withdrawn 
by  means  of  Leech's  trocar.  In  almost  every  instance,  Dr. 
Leech  assures  me  that  some  of  the  fibres  appear  more  or  less 
healthy  (a),  while  others  have  lost  their  normal  striation ;  their 
contents  are  granular,  but  they  are  not  much  diminished  in  size 
(6).  A  large  number  are,  however,  reduced  to  slender  and 
transparent  fibres;  their  surfaces  are  covered  by  nuclei;  the 
transverse  striation  is  still  distinctly  visible,  although  it  is  very 
faint  (c).  At  times  two,  or  even  three,  nuclei  may  be  seen  close 
together,  suggesting  that  they  have  been  derived  by  proliferation 
from  one  nucleus  originally.  The  nuclei  may  also  be  observed 
to  project  distinctly  from  the  surface  of  the  atrophied  fibre,  and 
it  is  therefore  probable  that  they  have  been  derived  either  from 
the  nuclei  of  the  sarcolemma  or  of  the  endomysium. 

(2)  Nervous  System. — The  lesions  which  have  been  found  in 
the  spinal  cord  are  undoubtedly  the  most  interesting  and  impor- 
tant of  all  those  which  have  been  observed  in  atrophic  paralysis. 
For  a  long  time  theoretical  arguments  were  adduced  on  the  one 
hand  to  show  that  this  disease  was  a  nervous  affection  either  of 
spinal  or  peripheral  origin;  while  on  the  other  hand  it  was  main- 
tained that  the  seat  of  the  lesion  was  primarily  in  the  muscles, 
and  hence  it  was  called  "essential  paralysis."  Heine  declared 
in  favour  of  the  spinal  theory  of  the  disease  in  1860,  in  the 
second  edition  of  his  work.  This  view  was  also  adopted  by 
Duchenne,  but  it  was  not  confirmed  by  post-mortem  examination 
until  1864,  when  Cornil,^  a  pupil  of  Charcot,  first  recognised 
distinct  alterations  in  the  spinal  cord,  and  drew  special  attention 
to  the  atrophy  of  the  anterior  grey  horns.    Provost  and  Vulpian,^ 

'  Comil.    Comptes  rendus  de  la  Soc.  de  Biol.    1864.    p.  187. 
*  Provost  et  Vulpian.    Comptes  rendus  de  la  Soc.  de  Biol.    1866.    p.  215. 


884  SYSTEM  DISEASES   OF  THE 

however,  in  1866,  were  the  first  to  make  the  positive  observation 
that  the  essential  anatomical  lesion  was  situated  in  the  grey 
anterior  horn.  This  observation  was  subsequently  confirmed  by 
the  observations  of  Lockhart  Clarke,^  Charcot  and  Joffroy,^  and 
of  many  others. 

It  is  unnecessary  to  enter  into  a  minute  description  of  all  the 
published  reports  of  post-mortem  examinations  in  cases  of  infan- 
tile spinal  paralysis.  The  essential  anatomical  change  consists 
in  the  desti'uction  of  a  large  number  of  the  ganglion  cells  of  the 
anterior  horns,  and  this  lesion  is  the  cause  of  the  paralysis  and 
subsequent  atrophy.  The  lesion  is  commonly  more  or  less  diffused 
through  the  anterior  grey  horns,  but  it  generally  reaches  its 
greatest  intensity  at  the  cervical  and  lumbar  enlargements,  and 
as  a  rule  leaves  no  permanent  alteration  except  at  these  points. 
It  may  extend  at  certain  points  somewhat  backwards  towards 
the  posterior  horns,  and  also  forwards  and  outwards  to  the  antero- 
lateral columns,  and  the  anterior  roots  of  the  nerves  are  usually 
atrophied,  but  these  are  secondary  changes  and  do  not  appear  to 
be  necessary  to  the  production  of  the  symptoms.  The  cases 
upon  which  this  conclusion  is  based  may  be  divided  into  those 
which  have  been  observed  within  two  years  from  the  beginning 
of  the  disease,  and  those  which  have  been  observed  after  loDg 
intervals  of  time. 

Unfortunately  no  observations  have  yet  been  made  with 
respect  to  the  affection  during  the  first  few  days  or  weeks,  owing 
to  the  fact  that  the  disease  of  itself  is  not  fatal.  Dr.  Clifford 
Allbutt^  reports  the  case  of  an  infant  seven  months  old  who  was 
suddenly  paralysed  in  all  the  extremities.  Death  resulted  in 
a  short  time  from  implication  of  the  respiratory  nerves.  On 
post-mortem  examination  two  hsemorrhagic  clots  were  dis- 
covered in  the  cervical  region,  one  of  small  size  being  situated 
in  the  left  posterior  horn,  the  otber  being  larger  and  situated 
in  the  right  posterior  horn  and  lateral  column.      Dr.  AUbutt 


1  Johnson  (Z.)  and  Clarke  (L.).  "On  a  remarkable  case  of  extreme  muscular 
atrophy,  with  extensive  disease  of  the  spinal  cord."  Medico.-Chir.  Transactions, 
Vol.  LI.,  1868,  p.  249. 

^  Charcot  and  Jofifroy.  Cas  de  paralysie  infantile  spinale  avec  lesions  des  comes 
anterieur  de  la  substance  grise  de  la  moelle  ^piniere.  Arch,  de  Physioloeie,  Tome 
III.,  1870,  p.  134.  J         b    , 

^  AUbutt  (T.  CUfford).    The  Lancet.    Vol.  IL,  1870,  p.  84. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  885 

thinks  that  if  these  lesions  had  been  found  in  the  lower  dorsal 
region  the  infant  would  probably  have  survived,  and  the  case 
might  have  been  regarded  as  one  of  infantile  spinal  paralysis. 
It  is,  however,  much  more  probable  that  this  was  a  case  of 
hagmatomyelia.  An  instructive  case  is  reported  by  Dr.  Charle- 
wood  Turner^  in  the  Pathological  Transactions  for  1879.  A  child 
two  and  a  half  years  of  age  fell  on  her  back,  but  played  about  as 
usual  for  a  fortnight  afterwards,  and  then  became  suddenly 
paralysed  in  her  lower  extremities,  and  in  a  few  days  afterwards 
in  her  upper  extremities  likewise.  On  admission  to  the  London 
Hospital,  a  fortnight  after  the  beginning  of  the  attack,  all  the 
extremities  were  completely  paralysed,  reflex  action  in  them 
was  also  abolished,  there  was  absence  of  sensation  in  the  lower 
extremities,  and  the  stools  were  passed  involuntarily.  The  child 
had  an  attack  of  measles,  and  died  about  six  weeks  after  the 
commencement  of  the  paralysis.  On  post-mortem  examination, 
which  was  made  by  Mr.  R.  W.  Parker,  changes  were  observed  in 
the  anterior  horns  and  antero-lateral  columns  throughout  the 
whole  length  of  the  cord,  these  being  more  pronounced  on  the 
left  than  the  right  side.  A  patch  of  reddened  gelatinous-looking 
matter,  about  the  size  of  a  swan  shot,  was  observed  in  the  left 
anterior  grey  horn  about  the  centre  of  the  lumbar  enlargement. 
The  margin  of  the  patch  was  of  a  darker  colour  than  the  centre, 
"as  from  the  decolorisation  of  an  hsemorrhagic  extravasation," 
In  the  neighbourhood  of  this  hsemorrhagic  focus  the  nervous 
tissues  were  completely  disintegrated,  so  that  no  nerve  structure 
could  be  distinguished  in  the  anterior  grey  horn,  and  in  the  outer 
part  of  the  base  of  the  posterior  horn.  The  whole  grey  substance 
was  abundantly  infiltrated  with  leucocytes,  and  a  considerable 
number  of  them  was  also  observed  in  the  white  substance,  while 
thev  were  massed  in  great  numbers  in  the  sheaths  of  the  larere 
arterioles.  The  vesicular  column  of  Clarke  did  not  appear  to 
have  been  anywhere  affected.  In  the  portions  of  the  cord 
which  were  remote  from  the  seat  of  hsemorrhage,  the  nefvous 
structure  was  not  completely  destroyed,  although  many  other 
evidences  of  disease  were  observed.     This  case  tends  to  confirm 

'  Turner  (C).  "A  portion  of  the  spinal  cord,  with  drawings  and  microscopical 
specimens,  from  a  case  of  acute  anterior  poliomyelitis  in  a  child,  fatal  within  six 
weeks  from  the  onset,"  Transactions  of  the  Pathological  Society,  Vol,  XXX., 
1879,  p.  202. 


886 


SYSTEM  DISEASES  OF  THE 


Dr.  Allbutt's  theory  of  the  origin  of  the  disease.  It  is,  indeed, 
quite  probable  that  a  small  heemorrhage  into  the  substance  of 
the  anterior  horn  may  sometimes  be  the  starting  point  of  the 
affection. 

In  the  Pathological  Transactions  for  1879  the  case  of  a  child, 
aged  three  and  a  half  years,  who  had  suffered  from  an  attack  of 
infantile  paralysis  at  the  age  of  seventeen  months,  is  reported  by 
Dr.  Henry  Humphreys.^  On  admission  to  the  Pendlebury  Hos- 
pital the  child  presented  well-marked  talipes  calcaneus  of  the 
left  heel.  Soon  after  admission  the  patient  developed  a  severe 
attack  of  scarlet  fever,  from  which  she  died.  The  changes 
observed  by  Dr.  Humphreys  in  the  spinal  cord  were  limited 
to  the  lumbar  region,  and  consisted  mainly  of  a  remarkable 
diminution  in  the  number  of  the  ganglion  cells  belonging  to  the 
anterior  and  lateral  parts  of  the  left  anterior  grey  horn.  The 
annexed  diagram  {Fig.  191)  shows  the  condition  of  the  anterior 
cornua  at  the  middle  of  the  lumbar  region.  Dr.  Humphreys 
examined  eighty-seven  sections  of  the  lumbar  region  of  the  cord, 
and  averaged  the  number  of  cells  they  contained. 

Fig.  191. 


T  C 


•     X  7 

Fig.  191  (after  Humphreys).  The  letters  a,  b,  c  indicate  respectively  the  central, 
antero-lateral,  and  postero-lateral  groups  of  ganglion  cells.  On  the  left  side  the 
group  6  has  almost  entirely  disappeared,  causing  a  marked  falling  in  of  the  cir- 
cumference of  the  grey  matter.  The  groups  a  and  c  are  fairly  well  represented 
on  the  left  side,  but  the  cells  composing  them  are  not  so  numerous  as  on  the 
right.     The  internal  group  has  disappeared  from  both  sides. 


'Humphreys  (H.).     "Case  of  infantile  paralysis."    Transactions  of  the  Patho- 
logical Society,  Vol.  XXX.,  1879,  p.  211. 


SPINAL   CORD  AND   MEDULLA   OBLONGATA.  887 

The  other  most  notable  cases  which  have  been  reported  at  an 
early  period  of  the  disease  are  those  of  Roger  and  Daraaschino/ 
Roth,^  Leyden's^  second  case,  Parrot  and  Joffroy,*  a  case  briefly 
reported  by  Rinecker,^  which  was  examined  by  von  Reckling- 
hausen, one  which  Dr.  Taylor^  brought  under  the  notice  of 
the  Pathological  Society,  and  another  recently  reported  by 
Schultze.^  No  marked  changes  were  discovered  in  the  cord  with 
the  naked  eye  in  any  of  these  cases.  In  some  of  them  the 
substance  of  the  cord  seemed  tougher  at  the  level  of  the  cer- 
vical or  lumbar  enlargements,  and  the  antero-lateral  column  on 
the  side  affected  appeared  atrophied  and  distorted.  On  trans- 
verse section  the  anterior  grey  horns  were  observed  to  be  more 
or  less  discoloured,  diminished  in  volume,  and  sometimes  so 
soft  as  to  be  almost  diffluent,  while  the  anterior  roots  at  the 
level  of  the  parts  mainly  affected  were  found  grey,  translucent, 
and  atrophied. 

On  microscopical  examination  areas  of  softening  have  been 
found  in  the  anterior  horns  on  one  or  on  both  sides,  the  cervical 
and  lumbar  enlargements,  especially  the  latter,  being  the  parts 
most  frequently  affected.  The  diseased  area  may,  on  horizontal 
section,  be  found  in  the  anterior,  central,  or  lateral  part,  or  may 
occupy  the  whole  of  the  horizontal  extent  of  the  horn,  while  in 
longitudinal  extent  it  may  be  limited  to  a  small  portion  of  the 
lumbar  or  cervical  enlargements,  or  implicate  both  the  enlarge- 
ments and  a  considerable  part  of  the  dorsal  and  upper  cervical 
regions  of  the  cord.  The  substance  of  the  diseased  areas  was 
found  soft,  friable,  and  disseminated  with  numerous  granulation 
cells ;  there  was  an  increase  of  nuclei  and  connective  tissue ;  the 

'  Roger  and  Damaschino.  Gazette  M^dicale,  1871,  Nos.  41,  43,  45,  48,  51 ; 
Virchow's  Jahresb.,  Vol.  IL,  1871,  p.  45.  See  also  "Des  alterations  de  la  moelle 
epiniere  dans  la  paralysie  spinale  de  I'enfance  et  dans  I'atrophie  musculaire  pro- 
gressive."   Kevue  de  Medecine,  Tome  I.,  1881,  p.  81. 

*  Eoth.  Anatomischer  Befund  bei  spinaler  Kinderlahmung.  Virchow's  Archiv., 
Bd.  LVIIL,  1873,  p.  263. 

^  Leyden.  "  Beitrage  zur  pathologischen  anatomie  der  atrophischer  Lahmung 
der  Kinder  und  der  Erwachsenen."  Arch,  fiir  Psychiat.,  Bd,  VI.,  1876,  p.  271 ; 
uad  Klinik  der  Ruckenmarkskrankheiten,  Bd.  II. ,  1875,  p.  198. 

■*  Parrot  and  Jofifroy.    Arch,  de  Physiol.    Tome  III.,  1869,  p.  309. 

*Rinecker.  Jahrb.  d.  Kinderheilkunde.  N.  F.,  Bd.  V.,  1871,  p.  118;  und 
Berl.  klin.  Wochenschr.,  Bd.  VIIL,  1871,  p.  627. 

°  Taylor  (F.).  "  Spinal  cord  from  a  case  of  infantile  paralysis."  Transactions 
of  the  Pathological  Society,  Vol.  XXX.,  1879,  p.  197. 

'  Schultze  (Fr.).  "  Befund  bei  Spinaler  Kinderlahmung  nach  dreijahrigem 
Bestehen  derselben."    Neuroiogische  Centralb.,  Bd.  I.,  1882,  p.  434. 


888  SYSTEM  DISEASES   OF  THE 

blood-vessels  were  dilated  and  their  walls  thickened ;  many  of 
the  ganglion  cells  had  disappeared,  while  others  were  observed 
in  all  stages  of  degeneration  and  atrophy  ;  and  the  nerve  fibres 
and  axis  cylinders  had  completely  disappeared,  while  diffused 
changes  were  observed  considerably  beyond  the  limits  of  the 
softened  area.  The  antero-lateral  columns  have  occasionally 
been  found  diminished  in  size,  and  the  seat  of  a  slight  sclerosis. 
The  trabeculse  are  then  thickened,  and  individual  nerve  fibres 
are  atrophied  (Joffroy  and  Damaschino).  The  anterior  roots  are 
diminished  in  size,  and  show  signs  of  degenerative  atrophy  when 
examined  microscopically. 

Observations  have  been  made  from  seventeen  to  sixty  one 
years  after  the  origin  of  the  disease,  by  Cornil,^  Prevost  and 
David,^  Vulpian,  Lockhart  Clarke,  Charcot  and  Joffroy,^  Petitfils* 
and  Pierrot,  Leyden,^  Gombault,^  Dejerine,^  F.  Schultze,^  Duplaix,^ 
and  others. 

The  morbid  changes  which  have  been  observed  in  these  cases 
are  generally  the  same  as  in  those  which  have  been  examined 
within  two  years  from  the  onset  of  the  disease.  The  anterior 
horns  are  shrunk,  and  the  antero-lateral  columns  appear  to  the 
naked  eye  grey,  translucent,  and  atrophied.  The  posterior 
columns,  posterior  grey  horns,  and  vesicular  column  of  Clarke 
are  almost,  if  not  quite,  normal. 

On  microscopic  examination  circumscribed  lesions  are  found 
in  the  anterior  horns  at  the  lumbar  and  cervical  enlargements, 
and  in  addition  to  the  main  lesions  more  or  less  diffused  changes 
are  met  with  in  the  grey  substance  and  white  columns.  The 
diseased  foci  consist  of  a  more  or  less  firm,  fibrillated  connective 

1  Cornil.    Comptes  rendus  de  la  Snc.  de  Biol.     1863.    p.  187. 
^  Prevost  et  David.    Arch,  de  Physiol.     2'^e  g^rie,  Tome  I.,  1874,  p.  595. 
^Charcot   and  Joffroy.      "Cas    de    paralysie    infantile    spinale."      Arch,     de 
Physiologic,  Tome  II.,  1870,  p.  134. 

*  Petitfils  (A.).  Considerations  sur  I'atrophie  aigue  des  cellules  motrices.  These 
de  Paris,  1873. 

*  Leyden.  Klinik  du  Ruckenmarkskrankheiten.  Ed.  II. ,  1875,  p.  198 ;  and 
Arch.  f.  Psychiat.,  Bd.  VI.,  1875,  p.  271. 

'^  Gombault.    Archiv.  de  Physiologie.    1873.     p.  80. 

'  Dejerine  (J.).  "Note  sur  deux  cas  de  paralysie  infantile."  Progr^s  medical, 
Tome  VI.,  1878,  p.  423. 

^  Schultze  (F. ).  "  Zur  Lehre  von  den  spinalen  Kinderlahmung  und  der  analogen. 
Lahmung  der  Erwachsener."    Virchow's  Arch.,  Bd.  LXVIII.,  1876,  p.  109. 

"  Duplaix  (J.  B.).  Note  sur  un  cas  de  paralysie  infantile."  Eevue  de  Medecine, 
Nov.,  1882,  p.  9G6. 


SPINAL   CORD  AND  MEDULLA   OBLONGATA. 


889 


tissue,  which  is  rich  in  nuclei ;  the  blood-vessels  are  enlarged, 
and  probably  also  increased  in  number;  their  walls  are  thickened; 
granule  cells  are  generally  absent;  but  a  large  number  of  corpora 
amylacea  as  well  as  pigment  granules  are  met  with.  Many  of 
the  multipolar  ganglion  cells  and  all  the  nerve  fibres  are  more  or 
less  completely  destroyed  in  the  diseased  area ;  while  the  cells 
which  remain  are  found  in  all  stages  of  degenerative  atrophy, 
pigmentary  degeneration,  and  shrivelling  {Fig.  174,  1,  2,  3),  but 
perfectly  normal  cells  are  often  found  beyond  the  diseased  focus. 
Iq  the  portions  of  the  grey  horns  which  are  comparatively 
healthy,  such  as  the  dorsal  region,  the  ganglion  cells  are  less 
numerous  than  normal,  the  connective  tissue  is  increased,  and 
the  nuclei  are  abundant.  The  annexed  diagram  (Fig.  192)  well 
illustrates  the  morbid  alterations  which  are  usually  observed  in 
the  anterior  horns. 

The  antero-lateral  columns  may  exhibit  a  greater  or  lesser 
degree  of  sclerosis ;   the  neuroglia  is  thickened,   and   there  is 

Fig.  192. 


Fig.  192  (from  Charcot).  Transverse  Section  of  the  Spinal  Cord  taken  from  the  cer- 
vical region  of  a  woman,  aged  fifty  years,  who  died  in  the  Salpetriere,  of 
general  paralysis  of  the  insane,  and  who  was  the  subject  of  infantile  spinal 
paralysis  of  the  right  superior  extremity.  There  was  fibroid  atrophy  of  the 
right  anterior  comu,  and  atrophy  of  all  the  white  columns  of  the  corresponding 
side. 


890  SYSTEM  DISEASES  OF  THE 

generally  some  degree  of  atrophy  of  the  nerve  fibres.  The 
sclerosis  may  vary  greatly  in  extent ;  it  is  sometimes  confined 
to  the  immediate  vicinity  of  the  anterior  horns,  while  at  other 
times  it  is  diffused  over  the  whole  of  the  antero-lateral  columns, 
the  pyramidal  tract  being  specially  liable  to  suffer. 

The  anterior  roots  are  thin,  grey,  translucent,  and  the  greater 
part  of  their  nerve  fibres  are  atrophied;  the  connective  tissue  is 
often  infiltrated  with  fat  cells,  its  nuclei  are  abundant,  and  the 
walls  of  the  vessels  are  thickened. 

The  peripheral  nerves  undergo  degenerative  atrophy.  F. 
Schultze  found  increase  of  the  interstitial  connective  tissue,  with 
atrophy  of  the  nerve  fibres. 

The  tendons  appear  as  thin,  narrow  bands,  and  are  found  to 
be  much  atrophied  when  compared  with  the  corresponding 
healthy  structures. 

The  bones  are  always  retarded  in  growth  when  the  disease 
occurs  in  childhood,  the  normal  protuberances  and  processes 
are  less  developed,  and  their  epiphyses  are  stunted.  The  medul- 
lary portion  is  relatively  increased,  its  fatty  contents  are  more 
abundant,  and  the  external  hard  lamella  of  the  bone  is  thin  and 
friable. 

The  ligaments  of  the  joints  are  thin  and  loose,  while  the 
articular  extremities  of  the  bones  are  stunted,  ground  off,  eroded, 
and  their  cartilages  attenuated.  The  alterations  in  the  joints, 
ligaments,  and  articular  cartilages  greatly  aid  the  muscular 
paralysis  in  the  production  of  the  different  forms  of  club-foot, 
and  the  various  other  deformities  already  described. 

The  arteries  are  slightly  diminished  in  calibre  (Charcot). 

The  skin  and  internal  organs  are  either  normal  or  only  show 
changes  which  have  no  necessary  connection  with  the  spinal 
disease.  The  brain  is  normal.  In  one  case  Sander^  found  the  two 
ascending  convolutions  and  the  paracentral  lobule — the  motor 
area  of  the  cortex  in  relation  with  the  paralysed  parts — com- 
paratively diminished  in  size,  but  as  the  spinal  disease  was 
associated  with  idiocy,  the  connection  between  the  atrophy  of 
the  cortex  and  the  spinal  lesion  may  have  been  merely  acci- 
dental    An  unexceptionable  case  of  this  kind  has  recently  been 

^  Sander  (WilL).  "Ueber  Riickwirkung  der  spinalea  Kinderlahmung,  &c." 
Centralbl.  f.  die  med.  Wissensch.,  1875,  Nr.  15. 


SPINAL   CORD  AND   MEDULLA  OBLONGATA.  891 

reported  by  Rumpf.^  The  patient  had  a  paralytic  attack  of 
hemiplegic  distribution  when  he  was  three  years  old,  and  died 
at  the  age  of  fifty ;  the  right  anterior  grey  horn  was  atrophied 
the  whole  length  of  the  cord,  there  was  no  secondary  degenera- 
tion of  the  lateral  column,  and  the  left  central  convolutions  were 
diminished  in  size,  while  the  left  weighed  seven  grammes  less 
than  the  right  hemisphere. 

Almost  all  pathologists  now  regard  the  primary  lesion  as 
an  inflammation  of  the  anterior  grey  horns,  although  the  cases 
reported  by  Drs.  Clifford  Allbutt  and  C.  Turner  appear  to 
show  that  a  slight  haemorrhage  into  the  grey  substance  may 
occasionally  be  the  starting  point  of  the  morbid  process.  The 
inflammatory  process  spreads  in  a  more  or  less  diffused  manner 
along  the  greater  part  of  the  anterior  horns,  but  attains  its 
greatest  intensity  in  the  lumbar  and  cervical  enlargements,  and 
in  these  localities  distinct  areas  of  softening,  and  destruction 
of  the  multipolar  ganglion  cells  are  produced.  When  the 
inflammation  subsides,  a  gradual  improvement  takes  place  in 
those  places  where  the  destruction  of  the  grey  substance  has 
been  incomplete;  but  where  the  nerve  structure  has  been 
thoroughly  disintegrated  there  is  a  gradual  development  of 
cicatricial  connective  tissue  in  its  place.  The  antero-lateral 
columns  become  secondarily  affected,  and  when  the  lesion  takes 
place  during  childhood  they  become  retarded  in  their  develop- 
ment, appear  narrow  and  atrophied,  and  cause  a  considerable 
change  in  the  form  of  the  spinal  cord. 

Whether  this  affection  is  to  be  regarded  as  a  parenchymatous 
or  an  interstitial  affection  is  not  yet  settled.  Charcot  and  others 
support  the  former  view  ;  while  Roger  and  Damaschino,  Roth  and 
others,  are  in  favour  of  the  latter.  Dujardin-Beaumetz,  however, 
suggests  that  both  tissues  become  inflamed  at  the  same  time,  and 
that  the  myelitis  is  both  parenchymatous  and  interstitial. 

§  393.  Morbid  Physiology. — Infantile  spinal  paralysis  is  one  of 
the  diseases  the  morbid  anatomy  of  which  has  largely  contributed 
to  clear  up  our  knowledge  of  the  functions  of  the  grey  anterior 
horns.      The   multipolar   cells   probably    constitute    ganglionic 

'  Eumpf .  "  Ein  Fall  von  spinaler  Kinderlahmung  mit  Atrophie  der  motorischen 
Himpartien."    Neurologisclie  Centralb.,  Bd.  L,  1882,  p.  476. 


892 


SYSTEM  DISEASES   OF  THE 


centres,  both  for  reflex  action  and  for  the  transmission  of 
impulses  received  through  the  pyramidal  tracts,  and  when  they 
are  destroyed  both  reflex  and  voluntary  actions  are  impaired  or 
abolished  according  as  the  destruction  of  the  cells  is  complete 
or  incomplete.  Destruction  of  these  cells  is  also  followed,  as  we 
have  seen,  by  various  trophic  changes  in  the  muscles,  bones, 
tendons,  and  joints. 

As  already  mentioned,  I  believe  that  the  ganglion  cells  of  the 
anterior  grey  horns  which  constitute  the  spinal  centre  for  the 
regulation  of  the  movements  of  a  muscle  also  constitute  for  it 
a  trophic  centre.  Most  muscles  are,  however,  connected  with 
fundamental  and  accessory  ganglion  cells,  and  it  is  only  when 
the  connection  between  the  former  and  the  muscle  is  severed 
that  profound  effects  both  upon  its  motor  power  and  nutrition 
are  produced.     The  acute  nature  of  the  lesion  in  infantile  para- 

FiG.  193. 


Fig.  193  (from  Charcot).  Section  of  the  Spinal  Cord  in  the  Lumhar  Region,  from 
a  case  of  infantile  paralysis.— A,  Left  anterior  cornu,  healthy ;  a,  Healthy 
median  group  of  ganglion  cells.  B,  Right  anterior  cornu ;  h.  Median  group  of 
ganglion  cells.  The  cells  are  destroyed,  and  the  group  is  represented  by  a 
patch  of  sclerosis. 


SPIXAL   CORD  AND  MEDULLA   OBLONGATA.  893 

lysis,  as  well  as  its  localisation,  is  well  adapted  to  sever  the 
muscles  from  their  connection  with  the  fundamental  cells,  even 
if  the  latter  were  to  remain  themselves  entirely  unaffected.  In 
a  case  observed  by  Charcot,  for  instance  {Fig.  193),  the  lesion 
occupied  a  position  in  which  only  a  few  of  the  fundamental  cells 
w/)uld  be  injured,  yet  a  large  number  of  fibres,  as  they  converge 
to  pass  out  to  the  anterior  roots,  must  have  been  destroyed,  and. 
the  effect  would  consequently  be  very  similar  to  that  which 
would  follow  a  peripheral  lesion  of  the  nerve.  The  similarities 
between  the  clinical  phenomena  of  infantile  spinal  parah'sis  and 
peripheral  disease  of  the  nerves  are  too  obvious  to  require 
pointing  out.  The  case  is  wholly  different  when  we  have  to 
do  with  a  chronic  and  gradually  progressive  affection  like  pro- 
gressive muscular  atrophy,  in  which  the  accessory  cells  are  first 
attacked,  and  the  disease  by  slow  and  successive  steps  gradually 
invades  the  more  fundamental  cells.  In  such  a  disease  we  may 
expect  that  the  clinical  symptoms  of  paralysis  and  atrophy  will 
pursue  a  totally  different  course  from  that  which  obtains  in 
infantile  spinal  paralysis. 

The  fact  that  the  disease  occurs  in  certain  circumscribed  areas 
explains  the  distribution  and  extent  of  the  paralysis,  and  the 
immunity  of  certain  muscles  and  groups  of  muscles.  The  acute 
inflammatory  nature  of  the  process  explains  the  sudden  appear- 
ance of  the  paralysis  as  well  as  the  fever  and  other  violent 
symptoms  which  occur  at  the  onset  of  the  dis'ease.  The  resolu- 
tion of  the  acute  inflammation,  in  part  or  in  whole,  explains  the 
rapid  disappearance  of  the  first  severe  symptoms  and  the  partial 
or  complete  restitution  of  the  paralysed  muscles  which  afterwards 
takes  place. 

§  394.  Diagnosis. — The  symptoms  of  acute  anterior  polio- 
myelitis are  so  definite  and  characteristic  that  it  is  not  easy  to 
confound  it  with  any  other  disease.  We  must,  however,  be 
careful  not  to  regard,  as  true  instances  of  this  affection,  every 
case  of  spinal  paralysis  which  arises  in  childhood,  even  if 
accompanied  with  atrophy. 

Hcematomyelia,  or  heemorrhage  into  the  grey  substance,  say 
of  the  lumbar  region,  may  produce  sudden  paralysis,  which  is 
followed  by  muscular  atrophy,  loss  of  reflex  excitability,  and  the 


894  SYSTEM  DISEASES  OF   THE 

reaction  of  degeneration  in  the  related  parts;  but  the  initial 
fever  is  absent,  the  invasion  is  more  sudden  even  than  that  of 
infantile  spinal  paralysis,  the  former  being  almost  apoplectiform 
in  its  onset,  and  disturbances  of  sensibility,  paralysis  of  the 
sphincters,  and  bed-sores  are  present.  If  the  lesion  is  situated 
in  the  cervical  enlargement,  some  of  the  muscles  of  the  upner 
extremity  will  be  found  atrophied,  while  one  or  both  the  lower 
extremities  are  likely  to  be  the  subjects  of  spasmodic  paralysis 
from  injury  to  the  lateral  columns. 

In  acute  central  or  transverse  myelitis,  cutaneous  anaesthesia, 
paralysis  of  the  sphincters,  and  bed-sores  are  almost  invariably 
present.  The  reflex  excitability  is  increased  in  transverse 
myelitis,  and,  as  a  rule,  there  is  no  atrophy. 

In  myelitis  from^  compression,  disturbances  of  sensibility, 
paralysis  of  the  bladder,  tremors  of  the  lower  extremities,  in- 
creased reflex  excitability,  severe  pains,  and  affections  of  the 
vertebral  column  are  present,  and  the  general  health  usually 
suffers  greatly,  but  there  is  either  no  muscular  atrophy,  or  the 
muscles  which  are  innervated  from  the  cord  at  the  level  of  the 
lesion  alone  suffer. 

From  cerebral  hemiplegia}  occurring  in  children,  this  disease 
may  be  distinguished  by  the  different  commencement  of  the 
former  disease,  by  the  implication  of  the  facial  nerve,  and  by  the 
facts  that  in  cerebral  paralysis  there  is  no  muscular  atrophy,  that 
the  electrical  irritability  is  preserved,  and  that  there  is  increased 
reflex  excitability  of  the  tendons.  The  spastic  paraplegise  of 
infancy  have  for  many  years  been  mistaken  for  cases  of  true 
atrophic  infantile  paralysis.  The  former  affection  is  generally 
congenital,  muscular  tension  is  provoked  by  passive  movements 
of  the  affected  limbs,  the  electrical  reactions  of  the  muscles  are 
normal,  and  active  spasms  of  the  gastrocnemii  supervene  when 
the  feet  are  placed  upon  the  ground. 

Progressive  muscular  atrophy  develops  slowly  and  gradually, 
and  the  wasting  of  the  muscular  tissue  precedes  the  paralysis, 
while  the  electrical  irritability  is  retained  for  a  long  time. 

Paralysis  following  obstetric  operations  is  observed  imme- 
diately after  birth,  the  initial  fever  is  absent,  and  the  seventh 
nerve  is  the  one  most  frequently  affected,  while  it  is  only  very 

»  Adams.    The  Lancet.    Vol.  II.,  1877,  p.  768. 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  895 

rarely  affected  in  anterior  poliomyelitis.  When  the  arm  has 
been  paralysed  by  pressure  of  the  blades  of  the  forceps  on 
the  brachial  plexus,  anaesthesia  remains  with  the  paralysis. 

Amyotrophic  lateral  sclerosis  begins  in  the  upper  extremities, 
which  become  more  or  less  paralysed  and  wasted,  while  the 
antagonists  of  the  paralysed  muscles  become  rigid  and  con- 
tracted ;  the  arm  is  held  tightly  to  the  body,  the  forearm  is 
flexed  and  pronated,  and  the  hands  and  fingers  are  strongly 
flexed,  while  the  lower  extremities  are  the  subjects  of  a  spasmodic 
paralysis.  The  initial  fever  is  absent,  and  the  subsequent  progress 
of  the  disease  differs  totally  from  that  of  anterior  poliomyelitis. 

The  peripheral  paralysis  of  single  groups  of  muscles  from 
pressure  on  their  nerves  by  tight  bandaging  or  other  causes  will 
be  distinguished  from  anterior  poliomyelitis  by  the  absence  of  the 
characteristic  initial  stage,  the  strict  limitation  of  the  paralysis 
to  the  area  of  distribution  of  a  single  nerve  trunk,  the  occurrence 
of  an  injury  to  the  nerve,  the  presence  of  disturbances  of  sensi- 
bility, and  the  rapid  recovery  which  generally  takes  places. 

§  895.  Prognosis. — Anterior  poliomyelitis  does  not  appear 
ever  directly  to  threaten  life  ;  and  consequently,  so  far  as  life  is 
concerned,  the  prognosis  is  very  favourable.  It  is,  however, 
possible  that  some  of  the  children  who  die  from  convulsions  may 
be  suffering  from  the  initial  stage  of  this  affection,  although  this 
opinion  has  not  yet  been  confirmed  by  post-mortem  examination. 

So  far  as  complete  recovery  is  concerned  the  prognosis  is  un- 
favourable. In  recent  cases,  therefore,  the  only  prognosis  we  are 
warranted  in  making  is,  that  recovery  will  take  place  to  a  very 
considerable  extent,  but  that  a  certain  amount  of  permanent 
paralysis,  with  atrophy  and  deformity,  is  likely  to  be  left 
behind.  Judging  from  the  case  of  spinal  paralysis  of  the  adult 
which  has  just  been  described,  in  which  complete  recovery  had 
taken  place,  and  from  several  cases  recorded  by  Proust  and 
Comby^  in  which  almost  complete  restitution  was  obtained,  I 
think  it  probable  that  the  prognosis  is  quite  as  favourable  in  the 
atrophic  spinal  paralysis  of  adults  as  in  that  of  infants,  provided 
the  lesion  be  not  a  very  extensive  one.  The  electrical  reactions  of 

•  Proust  et  Comby.  "Contribution  a  I'etude  des  paralyaies  spinales  ant^rieures 
aigues."    Progres  Medical,  Tome  IX.,  1881,  pp.  923,  943,  et  962. 


896  SYSTEM  DISEASES  OF  THE 

the  paralysed  muscles  form  a  valuable  aid  in  prognosis.  If  the 
faradic  contractility  of  certain  muscles  and  nerves  is  diminished 
at  the  end  of  five  days  and  abolished  during  the  course  of  the 
second  week,  these  will,  according  to  the  law  of  Duchenne,  remain 
permaneatly  paralysed  and  atrophied;  and,  conversely,  when  it  is 
not  abolished  by  the  twelfth  day/  the  muscles  will  regain  their 
motor  power,  and  the  restoration  will  be  the  more  prompt  and 
complete  the  less  their  faradic  irritability  is  diminished.  After 
the  second  week  the  galvanic  current  may  be  usefully  employed 
to  test  the  probability  of  the  degree  of  recovery  which  may  be 
expected  in  the  paralysed  muscles.  So  long  as  a  muscle,  or  even 
a  portion  of  the  muscle,  responds  in  the  slightest  degree  to  either 
current,  a  certain  degree  of  recovery  of  motor  power  may  be 
expected. 

The  muscles  that  do  not  recover  a  certain  amount  of  motor 
power  during  the  first  few  months  seldom  recover  at  a  later 
period ;  and  after  nine  months  of  complete  paralysis  all  hope  of 
recovery  may  be  abandoned,  although  even  then  slight  and 
partial  improvement  may  occur  under  appropriate  treatment. 

The  usefulness  of  the  paralysed  limbs  may,  however,  be  greatly 
improved  by  means  of  orthopoedic  operations,  gymnastics,  and 
electrical  treatment.  The  prognosis  in  this  respect  will  depend 
upon  the  degree  and  extent  of  the  paralysis  and  atrophy,  the 
amount  of  deformity  already  present,  the  age  of  the  patient,  and 
the  duration  of  the  disease  at  the  beginning  of  the  treatment. 

§  896.  Treatment. — The  treatment  may  be  subdivided  into 
that  which  is  appropriate  during  the  acute  initial  stage  and  that 
which  is  to  be  adopted  during  the  subsequent  stages  of  paralysis, 
atrophy,  and  deformity.  During  the  initial  febrile  stage  absolute 
rest  in  bed  must  be  enjoined,  and  the  patient  should  be  placed 
in  the  prone  position  if  possible,  or  at  least  on  his  side,^  but 
beyond  giving  a  saline  mixture  and  a  purgative,  if  required,  qo 
further  medicinal  treatment  is  necessary.  If  the  nature  of  the 
disease  be  detected  at  an  early  period,  an  ice  bag  may  be  applied 


*  Miiller  (Franz).     Die  acute  atrophische  spinallahmung  Erwachsenen.    Stutt- 
gart, 1880.    p.  76  et  seq. 

*  Gowers  (W.  E.*.     "  Remarks  on  acute  spinal  paralysis."    The  British  Medical 
Journal,  Vol.  I.,  1882,  p.  729. 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  897 

to  the  spine.  Ergotine  has  been  employed  subcutaneously  in 
doses  of  one-fourth  of  a  grain  for  a  child  from  one  to  two  years 
of  age,  one-third  of  a  grain  for  one  from  three  to  five  years,  half 
a  grain  for  children  from  five  to  ten  years  of  age,  and  a  grain  for 
patients  upwards  of  ten  years  of  age,  repeated  either  daily  or 
twice  a  day,  according  to  the  severity  of  the  symptoms  as  tested 
by  the  degree  of  fever  (Althaus).  Belladonna  has  also  been 
employed  with  apparent  benefit  in  this  stage  of  the  affection. 
After  the  fever  has  subsided  iodide  of  potassium  may  be  adminis- 
tered in  appropriate  doses  with  the  view  of  promoting  the 
absorption  of  effused  products,  while  mild  counter  irritants  might 
be  applied  along  the  spine. 

A  nutritious  and  abundant  diet  should  be  prescribed  with 
prolonged  sojourn  in  the  open  air,  mountainous  or  sea  air  being 
especially  useful.  The  thermal  springs  of  Wildbad,  Teplitz,  or 
Gastein  have  been  specially  recommended. 

The  constant  galvanic  current  should  be  used  as  soon  as  the 
fever  has  subsided,  and  it  should  be  made  to  pass  through  the 
diseased  area  of  the  cord.  If  the  leg  alone  be  affected,  the 
current  should  be  directed  to  the  lumbar  enlargement ;  if  an  arm 
only  be  affected,  the  cervical  enlargement  must  be  acted  upon  ; 
and  if  the  muscles  of  the  trunk  suffer  likewise,  the  whole  dorsal 
region  of  the  cord  should  be  included  iii  the  circuit.  In  order  to 
reach  the  cord,  it  is  better  to  place  one  pole  on  the  spine,  and  to 
apply  the  other  to  the  anterior  surface  of  the  trunk.  The 
electrodes  should  be  large,  the  one  placed  over  the  back  being 
large  enough  to  cover  the  entire  diseased  area;^  the  force  of  the 
current  should  be  gentle,  and  the  application  continued  for  from 
three  to  ten  minutes  according  to  the  extent  of  the  lesion.  Erb 
has  recommended  that  the  current  be  sent  through  the  cord  first 
in  one  direction  and  then  in  another,  but  Althaus  prefers  the 
action  of  the  positive  pole  alone.  The  treatment  must  be  con- 
tinued for  a  long  time,  and  afterwards  repeated  at  intervals  for 
years. 

At  the  later  period  of  the  disease,  when  atrophy  of  the  para- 
lysed muscles  has  set  in,  a  peripheral  application  of  the  constant 
current  and  faradisation  of  the  paralysed  nerves  and  muscles 

>  Erb  (W.).  "  On  the  diseases  of  the  spinal  cord."  Ziemesen'a  CyclopsBdia, 
Vol.  XIII.,  1878,  p.  708. 

VOL.  L  FFF 


898  SYSTEM  DISEASES   OF  THE 

may  be  combined  with  the  application  of  the  current  to  the 
spine.  So  long  as  the  nerves  and  muscles  have  not  entirely  lost 
their  faradic  irritability,  local  application  of  the  faradic  current 
will  be  of  service.  The  constant  current,  however,  is  on  the 
whole  superior  to  the  induced,  even  for  peripheral  application, 
since  in  the  majority  of  cases  it  is  the  only  agent  which  will 
produce  any  muscular  response.  Appropriate  gymnastic  exer- 
cises of  the  muscles,  shampooing  and  friction,  with  or  without 
stimulating  linaments,  may  be  employed  as  adjuncts  to  the 
electrical  treatment.  When  the  case  comes  under  treatment,  six 
months  or  longer  after  the  invasion  of  the  disease,  iodide  of  potas- 
sium is  useless,  and  greater  benefit  may  be  expected  from  phos- 
phorus and  cod-liver  oil.  Arsenic  has  also  been  highly  recom- 
mended at  this  stage  of  the  disease.  The  use  of  strychnia  has  been 
advocated,  especially  in  the  form  of  subcutaneous  injection,^  but 
I  have  never  seen  any  good  results  from  its  employment,  although 
I  have  seen  the  remedy  pushed  to  an  almost  dangerous  degree. 
A  strenuous  endeavour  should  be  made  to  prevent  the  occurrence 
of  contractures  and  deformities.  A  great  deal  may  be  done  in 
this  respect  by  means  of  electrical  treatment,  gymnastics,  and 
light  frictions.  In  guarding  against  talipes  equinus,  Volkmann 
advises,  during  the  earliest  stages  of  the  disease,  that,  when  the 
patient  is  lying  down,  the  foot  be  fastened  to  a  light  footboard 
by  means  of  a  flannel  bandage,  and  its  extremity  drawn  up 
somewhat  towards  the  leg.  Children  should  wear  stout  laced 
boots,  with  a  steel  shank  on  the  outer  or  inner  side,  or  with  the 
sole  slightly  thicker  on  one  side,  so  that  the  tendency  to  the 
development  of  talipes  varus  or  valgus  may  be  counteracted. 
The  formation  of  talipes  calcaneus^  may  be  counteracted  by 
supplementing  the  defective  action  of  the  posterior  muscles  of 
the  leg  with  a  strong  indiarubber  tractor,  fastened  below  to  a 
stud  projecting  from  the  heel  of  the  shoe  at  a  point  corresponding 
to  the  insertion  of  the  tendo  Achillis,  and  above,  below  the  knee, 
to  a  padded  channel  of  sheet  iron,  carried  by  a  splint  that  is  pro- 
longed to  the  inner  side  of  the  foot,  and  inserted  into  the  sole. 
Attempts  have  been  made  to  supply  the  place  of  other  groups  of 

>  Barwell  (R.).     "Clinical  lectures  on  infantile  paralysis  and  its  resulting  defor- 
mities."   The  Lancet,  Vol.  II.,  1872,  p.  2. 

*  Volkmann  (A.).     The  Lancet.     Vol  I.,  1S70,  p.  404. 


/ 


/ 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  899 

paralysed  muscles  by  means  of  india-rubber  bands,  but  these  have 
not  been  attended  with  much  success.  In  the  severer  forms  teno- 
tomy and  forcible  means  of  correction  must  be  adopted ;  but  it 
is  no  part  of  this  work  to  enter  into  the  details  of  orthopoedic 
surgery,  and  the  reader  must,  therefore,  be  referred  to  special 
works  for  the  further  discussion  of  the  subject. 


(2)  Paralysis  Ascendens  Acuta. 

Acute  Ascending  Paralysis — Landry^s  Paralysis. 

§  397.  Definition. — Acute  ascending  paralysis  is  characterised 
by  a  motor  paralysis  which  generally  begins  in  the  lower  ex- 
tremities, spreads  pretty  rapidly  over  the  trunk  to  the  upper 
extremities,  and  usually  involves  the  medulla  oblongata ;  the 
general  sensibility,  and  the  functions  of  the  bladder  and  rectum 
are  either  unaffected  or  only  slightly  implicated,  and  there  is  no 
decided  atrophy  of  the  muscles  and  no  alteration  of  their  elec- 
trical excitability. 

§  398.  History. — Cases  of  tHs  disease  were  described  by  Ollivier, 
Walford,^  and  others,  and  it  appears  that  Cuvier  died  of  it  in  1832.  The 
disease,  however,  was  not  recognised  as  a  separate  affection  imtil  1859, 
when  Landry^  described  some  cases  under  the  name  of  "  Paralysie  Ascen- 
dante  Aigue."  Kussmaul^  also  described  two  cases  in  the  same  year.  Since 
Landry's  pubHcation  reports  of  cases  have  multiphed  ;  although  at  times 
instances  of  other  diseases,  such  as  of  acute  central  myehtis,  and  of  sub- 
acute anterior  pohomyelitis,  have  been  described  under  this  name. 

§  399.  Etiology. — Very  little  is  known  with  respect  to  the 
causation  of  this  disease,  and  at  times  it  arises  in  the  absence  of 
recognisable  predisposing  or  exciting  causes.  Most  of  the  reported 
cases  have  occurred  between  the  ages  of  twenty  and  forty,  and 
men  are  more  frequently  attacked  than  women. 

Exposure  to  cold  is  probably  the  most  frequent  exciting  cause. 
Some   cases   have   occurred    during   convalescence   from   acute 

*  Walford.  Softening  of  the  spinal  cord.  Association  Medical  Journal,  l8o3, 
Nov.  11,  p.  993. 

'^  Landry  (O. ).  "Note  sur  paralysie  ascendante  aigue."  Gaz.  Hebdom.,  1859, 
pp.  472  et  486. 

'  Kussmaul.  "Zwei  Falle  von  todtlichen  Paraplegie  ohne  nachweisbaren 
Ursache."    1859,    Abstr.  Canstatt's  Jahresb.,  Bd.  III.,  1860,  p.  67. 


900  SYSTEM  DISEASES  OF  THE 

diseases,  as  typhoid  fever/  pleurisy,  or  variola,  and  a  few  have 
followed  suppression  of  the  menses.  Various  authors  regard 
syphilis  as  a  frequent  cause  of  the  disease,  while  others  believe 
that  it  is  sometimes  caused  by  rheumatism,^  but  it  is  doubtful  how 
far  these  opinions  are  correct.  A  case  is  recorded  by  Dr.  Myrtle^ 
which  was  caused  by  alcoholic  excess,  but  as  no  electrical  exami- 
nation was  made  of  the  paralysed  nerves  and  muscles  the  diag- 
nosis must  be  considered  doubtful. 

§  400.  Symptoms. — The  paralytic  phenomena  are  generally, 
though  not  always,  preceded  by  various  premonitory  symptoms, 
such  as  slight  fever,  shooting  pains  in  the  back  and  limbs,  formi- 
cation and  numbness  in  the  feet  and  finger  tips,  and  a  feeling  of 
great  weariness,  debility,  and  general  discomfort.  These  may 
last  for  one  or  several  days,  and  they  have  occasionally  existed 
for  six  wepks. 

The  characteristic  symptoms  of  the  disease  now  make  their 
appearance.  Great  weakness  of  the  lower  extremities  is  soon 
complained  of,  which  increases  to  such  an  extent  as  to  render 
standing  and  walking  impossible.  The  patient  can  for  a  short 
time  execute,  when  lying  down,  the  individual  movements  of  the 
legs,  but  this  power  is  soon  lost.  The  paralysis  appears  first  in 
the  muscles  which  move  the  feet,  then  in  those  which  move  the 
legs,  and  at  last  in  the  muscles  of  the  thighs,  and  thus,  in  the 
course  of  a  few  days,  the  lower  extremities  may  be  completely 
paralysed.  The  legs  now  lie  flaccid  and  powerless,  there  is  no 
resistance  to  passive  movements  of  them,  and  there  is  complete 
absence  of  muscular  tension  and  contractures. 

The  paralysis  advances  steadily  upwards,  the  muscles  of  the 
trunk  are  invaded,  and  sitting  up  is  rendered  impossible ;  while 
the  acts  of  coughing,  sneezing,  and  defecation  are  weak  and  in- 
effective through  paralysis  of  the  abdominal  muscles. 

The  muscles  of  the  upper  extremities  are  now  attacked ;  they 
are  implicated,  indeed,  before  the  abdominal  muscles,  and  soon 

'  Leudet.  "  Paralysie  ascendante  aiguS,  rapidement  mortelle,  survenant  dans  le 
convalescence  de  le  fievre  typhoi'de."    Gaz.  des  hop.,  1861,  No.  58. 

^  Jones  (H.).  "Case  of  paralysis  of  obscure  origin,  probably  rheumatic  or 
neuralgic."    British  Medical  Journal,  Vol.  II.,  1866. 

'  Myrtle  (A.  S.).  "On  a  case  of  acute  ascending  paralysis;  chronic  alcoholism." 
British  Medical  Journal,  Vol.  II.,  1882,  p.  312. 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  901 

become  completely  paralysed.  The  hands  first  grow  weak,  and 
delicate  actions,  like  those  required  for  writing,  become  impos- 
sible. The  movements  of  the  forearm  become  more  and  more 
difficult,  and  those  of  the  shoulder-joint  are  soon  implicated,  the 
arms,  like  the  legs,  being  completely  relaxed  and  immovable. 
( disturbances  of  respiration  now  appear,  owing  to  paralysis  of  the 
intercostal  and  other  respiratory  muscles  of  the  trunk,  and  unless 
the  progress  of  the  disease  is  arrested  the  patient  soon  dies  from 
asphyxia. 

The  following,  according  to  Landry,  is  the  order  in  which  the 
muscles  are  affected  by  paralysis  : — 

1.  The  muscles  which  move  the   toes   and  foot,   then  the 

posterior  muscles  of  the  thigh  and  pelvis,  and  lastly  the 
anterior  and  internal  muscles  of  the  thigh. 

2.  The  muscles  which  move  the  fingers,  those  which  move  the 

hand,  and  the  arm  upon  the  scapula,   and   lastly   the 
muscles  which  move  the  forearm  upon  the  arm. 

3.  The  muscles  of  the  trunk. 

4.  The   muscles   of  respiration,   then   those   of  the  tongue, 

pharynx,  and  oesophagus. 

It  will  thus  be  seen  that  although  the  paralysis  pursues  a 
general  ascending  course,  yet  the  various  groups  of  muscles  are 
not  affected  in  the  same  relative  order  in  which  they  are  in- 
nervated from  the  cord.  The  muscles  of  the  hand,  for  instance, 
are  paralysed  before  those  of  the  abdomen,  yet  the  former  are 
innervated  from  the  cervical  and  the  latter  from  the  dorsal 
region  of  the  cord. 

Although  the  paralysis  begins  most  frequently  in  the  lower 
extremities  and  pursues  an  ascending  course,  yet  cases  are 
recorded  in  which  one  or  both  of  the  upper  extremities  were  the 
first  to  become  affected,  and  the  paralysis  in  these  cases  pursued 
a  descending  course.  The  disease  occasionally  begins  by  para- 
lysis in  the  region  of  distribution  of  the  bulbar  nerves;  it  then 
also  pursues  a  descending  course,  but  is,  as  might  be  expected, 
rapidly  fatal.  Cuvier  is  said  by  Pellegrino  Levi^  to  have  died  of 
this  acute  descending  paralysis. 

*  Pellegrino  Levi.  "  Contribution  a  I'^tude  de  la  paralysie  ascendante  aigue  ou 
extenso-progressive  aigue.'-    Arch,  gen^r.  de  m^d,,  6^  rf&ie,  Vol.  I,,  1865,  p.  129, 


902  SYSTEil  DISEASES   OF  THE 

The  disturbances  of  sensibility  are  quite  subordinate  to  the 
motor  paralysis,  although  they  are  not  entirely  wanting.  Patients 
frequently  complain  of  numbness  and  formication  in  the  fingers 
and  toes;  there  may  be  a  diminution  of  feeling  in  the  soles  of 
the  feet,  which  occasionally  extends  over  the  whole  of  the  lower 
extremities ;  and  pain  may  be  complained  of  at  the  beginning  of 
the  disease,  although  it  is  never  a  prominent  symptom.  Cuta- 
neous sensibility  is  usually  found  to  be  normal  on  objective 
examination,  although  it  may  be  diminished  at  the  periphery 
of  the  extremities ;  in  some  few  cases  there  is  almost  complete 
anaesthesia,  while  hyperalgesia  is  still  more  rarely  observed. 

A  considerable  amount  of  emaciation  may  appear  just  as 
occurs  during  the  course  of  any  other  acute  disease,  but  the 
paralysed  muscles  do  not  undergo  rapidly  progressive  atrophy, 
and  the  electrical  excitability  of  the  paralysed  nerves  and 
muscles  remains  normal.  But  a  case  is  reported  under  the  name 
of  acute  ascending  spinal  paralysis  by  Dr.  R  v.  d.  Yelden,^  from 
the  clinic  of  Leyden,  in  which  the  electrical  reactions  of  the 
affected  muscles  were  lost,  although  the  symptoms  in  other 
respects  corresponded  accurately  with  those  of  Landry's  paralysis. 
The  patient  was  a  man,  aged  fifty-four  years,  who  enjoyed  good 
health  up  till  about  four  or  five  weeks  before  his  admission  into 
the  hospital.  He  was  then  suffering  from  diarrhoea,  and  loss  of 
appetite,  but  there  was  no  fever,  and  beyond  a  remarkable  degree 
of  general  debility  no  mention  is  made  of  paralysis.  A  fortnight 
after  admission,  while  sitting  at  mid-day  near  the  stove,  he  sud- 
denly felt  a  painful  tingling  and  formication  in  his  lower  extre- 
mities, which  extended  to  his  arms  and  hands  towards  evening. 
He  experienced  great  difficulty  in  walking  towards  his  bed  and 
in  unbuttoning  his  clothes.  He  slept  well,  however,  during  the 
night,  and  in  the  morning  all  the  tingling  sensations  had  dis- 
appeared, but  the  lower  extremities  were  almost  completely  and 
the  arms  partially  paralysed.  The  muscles  of  the  arms  only 
contracted  feebly  to  a  strong  faradic  current,  and  they  failed  to 
react  to  the  constant  current,  while  the  muscles  of  the  lower 
extremities  remained  completely  reactionless  to  both  currents. 
There  were  no  contractures,  and  no  spasm;  the  cutaneous  reflexes 

>  Velden  (Eeinhard  v.  d.).     "Ein  Tall  von  acuter  aufsteigender  spinaler  Para- 
lysie."    Deutsches  Arch.  f.  klin.  Med.,  Bd.  XIX.,  1877,  p.  3S3. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  903 

were  absent ;  there  were  no  pains  in  the  lower  extremities  or 
along  the  vertebral  column,  either  spontaneously  or  on  percus- 
sion ;    every   form   of  cutaneous   sensibility   was   normal ;    the 
patient  knew  with  closed  eyes  the  position  of  his  limbs ;  the 
temperature  was  at  no  time  much  over  100°  F. ;  and  there  were 
bed-sores;  but  the  bladder  was  distended.      The  patient  died 
from  arrest  of  respiration  two  and  a  half  days  from  the  onset 
of  the  decided  paralytic  symptoms.     The  absence   of  sensory 
disturbances  and  of  bed-sores  seems  to  exclude  this  case  from 
the  category  of  cases  which  will  be  subsequently  described  as 
acute  central  myelitis,  and  the  complete  loss  of  the  electrical 
reactions  of  the  paralysed  muscles  makes  it  difficult  to  include 
it  amongst  the  diseases  under  consideration  at  present.     It  is 
scarcely  possible  that  the  electrical  reactions  of  the  muscles  could 
be  lost  twenty-four  hours  after  the  onset  of  the  paralysis,  and  it 
is,  therefore,  probable   that  the  "  remarkable  weakness "  from 
which  the  patient  is  said  to  have  suffered  on  his  admission  to 
the  hospital  indicated  a  certain  degree  of  paralysis.     Except  in 
its  rapid  course  and  fatal  termination  the  symptoms  in  this  case 
correspond  with  those  of  the  subacute  ascending  spinal  paralysis 
of  Duchenne,  and  they  are  best  explained  by  supposing  that  an 
acute  attack  had  supervened  upon  a  previously  existing  sub- 
acute or  chronic  process.     A  case  is  also  described  by  Shulz  and 
Schultze^  which  presented  the  general  characters  of  acute  ascend- 
ing paralysis,  but  in  which  there  was  a  rapid  diminution  of  the 
electrical  excitability.    Such  records  show  that  between  Landry's 
disease  and  chronic  atrophic  paralysis  transitional  cases  are  to  be 
met  which  show  the  essential  unity  of  the  two  affections. 

The  nutrition  of  the  skin  is  not  affected,  and  bed-sores  do 
not  occur.  In  a  case  reported  by  Eisenlohr^  there  was  transitory 
oedema  of  the  skin  with  redness  of  the  integument  over  various 
joints,  and  in  some  other  cases  a  profuse  secretion  of  sweat  has 
been  noticed,  but  no  other  vaso-motor  disturbance. 

Reflex  action  is  preserved  during  the  first  few  days  of  the 
disease,  it  then  diminishes  more  or  less  rapidly,  and  is  finally 
extinguished.    In  Eisenlohr's  case  an  increase  of  reflex  action  was 

'  Shulz  and  Schultze.     Arch.  f.  Psychiat.    Bd.  XIII.,  1882,  p.  457. 
"  Eisenlohr.    "  Zur  Lehre  von  den  acute  spinale  paralyse."    Arch,  fiir  Psychiat., 
Bd.  v.,  1874,  p.  219. 


904  SYSTEM  DISEASES  OF  THE 

observed.  In  a  case  examined  by  Westphal  the  patellar-tendon 
reactions  were  abolished.  A  case  of  this  affection,  which  will 
be  immediately  described,  came  under  my  own  observation,  in 
which  the  patellar-tendon  reactions  were  absent,  and  my  friend 
Dr.  Briggs,  of  Burnley,  has  communicated  to  me  an  undoubted 
example  of  the  disease,  and  these  reactions  were  also  absent. 

The  functions  of  the  bladder  and  rectum  are  usually  unaffected. 
In  some  few  cases  slight  disturbances  of  the  bladder  have  been 
met  with,  but  the  severe  paralysis  of  the  bladder  and  rectum, 
which  occurs  in  other  forms  of  central  myelitis,  has  never  been 
observed.     The  bowels  are  usually  constipated. 

The  general  health  is  as  a  rule  good,  and  in  the  majority  of 
cases  there  is  no  fever.  In  some,  however,  the  general  health  is 
disturbed,  and  febrile  symptoms  appear,  which  occasionally  may 
be  severe.  The  brain  is  entirely  unaffected  throughout  the 
whole  course  of  the  disease,  and  even  the  cerebral  motor  nerves 
are  not  implicated  until  the  terminal  period. 

§  401.  Course,  Duration,  and  Termination. — As  the  disease 
advances  upwards,  patients  complain  of  pain  and  stiffness  in 
the  neck,  and  the  muscles  of  that  region  become  paralysed, 
and  sometimes  there  is  paresis  of  the  facial  muscles.  The 
medulla  oblongata  is  soon  implicated,  and  then  the  functions 
of  articulation,  mastication,  deglutition,  and  ultimately  respira- 
tion are  interfered  with  ;  evidences  of  hypersemia  and  hypostatic 
congestion  of  the  lungs  appear,  and  the  patient  dies  from  asphyxia. 
Sometimes  the  pupils  have  been  unequal,  and  the  pulse  may 
become  very  frequent. 

The  duration  of  the  disease  is  somewhat  variable.  In  some 
cases  it  runs  its  course  and  ends  in  death  in  two  or  three  days, 
while  occasionally  it  lasts  from  two  to  four  weeks.  The  average 
duration  of  fatal  cases  is  from  eight  to  twelve  days. 

But  the  disease  may  end  in  recovery.  It  may  cease  to  pro- 
gress at  any  stage  of  its  development.  This  usually  takes  place 
before  the  nerves  of  the  medulla  oblongata  are  involved,  but 
recovery  has  been  known  to  take  place  even  after  disturbances 
of  respiration,  deglutition,  and  mastication  had  commenced. 

In  cases  which  run  a  favourable  course  improvement  takes 
place  at  an  early  period  of  the  disease,  the  parts  last  attacked 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  905 

by  the  paralysis  being  the  first  to  show  signs  of  improvement. 
The  patients  first  begin  to  use  their  hands,  after  a  time  they  are 
able  to  sit  up,  and  finally  after  another  considerable  interval  they 
are  able  to  stand  and  walk.  The  patients,  however,  often  com- 
plain for  a  long  time  of  debility,  and  recovery  is  liable  to  be 
interrupted  by  relapses. 

The  following  case,  which  I  had  an  opportunity  of  seeing 
several  times  in  consultation  with  my  colleague,  Mr.  Walter 
Whitehead,  appears  to  me  to  have  been  an  example  of  Landry's 
paralysis,  which  pursued  a  favourable  course  : — 

E.   L. ,  aged  twenty-three  years,  and  unmarried,  consulted  Mr. 

Whitehead  for  his  present  symptoms  for  the  first  time  on  December  1st, 
1882. 

The  patient  comes  of  a  healthy  family,  and  he  has  always  enjoyed  the 
best  of  health  up  to  the  date  of  the  present  illness.  He  has  been  guilty  of 
sexual  excesses,  and  had  slight  sores  on  his  penis  on  two  or  three  occasions, 
for  which  he  was  treated  by  Mr.  Whitehead.  He  never  had  swelling  of  the 
glands  in  the  groin,  sore  throat,  or  cutaneous  eruptions,  and  Mr.  Whitehead 
believes  that  these  sores  were  only  soft  chancres.  He  has  had  sexual 
intercourse  once  only  during  the  last  six  months,  and  states  that  he  has 
not  felt  much  desire  lately.  During  this  period,  however,  he  has  been 
greatly  troubled  with  noctin-nal  emissions ;  he  scarcely  ever  missed  having 
one  every  night,  and  sometimes  he  has  as  many  as  four  during  a  night. 
Some  weeks  ago  he  had  to  go  to  the  South  of  England,  and  there  consulted 
a  physician  on  account  of  these  emissions,  who  prescribed  a  mixture  of 
iron  and  quinine.  He  travelled  back  to  Manchester  on  November  27th, 
and  while  sitting  at  home  reading  on  November  29th  he  felt  considerable 
numbness  and  tingling  in  his  hands  and  fingers,  and  on  the  following  day 
these  uncomfortable  sensations  extended  to  his  feet  also.  On  the  second 
day  from  the  commencement  of  the  tingling  he  consulted  Mr.  Whitehead, 
who  took  a  serious  view  of  his  condition  and  ordered  him  to  bed.  During 
the  next  few  days  it  was  manifest  that  there  was  a  gradual  loss  of  motor 
power,  which  began  in  the  lower  extremities,  and  in  a  day  or  two  later 
extended  to  the  hands. 

December  10th  :  The  patient  was  seen  by  me  for  the  first  time  this 
morning.  He  hes  on  his  back  in  bed,  and  is  unable  to  raise  himself  to  a 
sitting  posture  or  to  turn  himself  in  bed.  He  has  sufficient  power  over 
each  lower  extremity  to  enable  him  to  raise  the  heel  from  the  bed,  but  to 
do  this  requires  a  great  efi'ort.  He  can  also  move  the  various  segments  of 
the  upper  extremities  upon  one  another  and  upon  the  body,  but  these 
actions  are  feebly  performed,  and  his  grasp  is  so  weak  that  his  pressure 
of  one's  hand  is  scarcely  perceptible.  The  breathing  is  slow  and  laboured, 
and  wholly  abdominal,  but  on  being  requested  to  raise  his  chest  he  can 
elevate  his  ribs,  but  to  effect  this  movement  evidently  costs  him  a  great 


906  SYSTEM  DISEASES  OF  THE 

effort.  The  reflex  of  the  sole  is  still  active,  but  the  patellar-tendon 
reactions  are  lost  on  both  sides.  There  was  no  opportunity  of  examining 
the  electrical  reactions  of  the  muscles.  The  right  pupil  is  in  a  state  of 
medium  dilatation,  while  the  left  is  in  a  condition  of  almost  maximum 
dilatation,  but  both  react  to  light.  The  optic  discs  are  normal  The 
patient  stiU  complains  of  the  numbness  and  tingling  in  his  hands  and  feet, 
but  there  is  no  diminution  of  any  form  of  sensibility  to  objective  exanaina- 
tion.  The  bowels  are  constipated,  but  beyond  this  there  are  no  disorders 
of  the  functions  of  the  bladder  and  rectum.  The  patient's  countenance  has 
a  dusky  appearance,  the  pulse  beats  80  in  the  minute,  the  temperature  is 
normal,  and  the  mental  faculties  are  perfectly  clear.  In  the  evening  of  the 
same  day  the  same  symptoms  continued,  and  in  addition  the  lower  jaw 
dropped,  and  there  was  slight  difl6.culty  in  swallowing,  but  the  patient  could 
put  his  tongue  out  and  move  it  in  all  directions.  Both  upper  eyelids 
drooped  considerably,  so  that  the  patient  had  a  sleepy  appearance,  as  in 
ophthalmoplegia  externa.  As  there  was  a  suspicion  of  syphilis  the  patient 
was  given  10  grains  of  iodide  of  potassium  thi-ee  times  a  day. 

December  11th :  The  symptoms  have  on  the  whole  remained  unchanged, 
but  the  patient's  face  is  decidedly  less  dusky  than  it  was  yesterday  morning ; 
the  dropping  of  the  lower  jaw  has  disappeared,  there  is  no  difficulty  in 
swallowing  fluids,  and  the  eyelids  are  more  open. 

December  14th :  The  patient  has  continued  to  improve  gradually  since 
last  report.  Two  days  ago  the  electrical  reactions  of  the  nerves  and  muscles 
were  tested  and  found  normal.  The  countenance  has  lost  all  its  dusky 
appearance,  and  the  patient  looks  bright  and  cheerful;  he  can  now  move 
his  hands  much  more  freely,  his  grasp  is  stronger,  and  he  can  elevate  his 
ribs  without  much  effort.  From  this  time  forwards  the  patient  steadily 
improved,  and  four  weeks  afterwards  Mr.  Whitehead  kindly  sent  him  to 
my  rooms  to  show  himself  ;  he  then  looked  quite  well,  and,  although  stiU 
complaining  of  general  weakness,  all  the  paralytic  symptoms  had  disap- 
peared. 

§  402.  Morbid  Anatomy. — Most  of  the  examinations  whicti 
have  hitherto  been  made  have  yielded  completely  negative  results 
both  as  regards  the  spinal  cord,  medulla  oblongata,  brain,  sym- 
pathetic nerves,  peripheral  nerve  trunks,  and  muscles.  The 
names  of  Vulpian,^  Hayem,^  Bernhardt,^  Westphal,*  Dejerine 
and  Goetz,^  who  have  conducted  the  examinations,  sufficiently 

'  Vulpian.    Legons  sur  les  maladies  du  systeme  nerveux.    1877.     p.  189. 

'^  Hayem.     "  Paralysie  ascendante  aigue."    Gaz.  des  h6p.,  1867,  Nr.  102. 

^  Bernhardt.  "  Beitrag  zur  Lehre  von  der  acuten  allgemeinen  Paralyse."  Berl. 
klin.  Wochensch.,  Bd.  IV.,  1871,  p.  561. 

*Westphal  (C).  "  Ueber  einige  Falle  von  acuter  todtlicher  Spinallahmung. 
Arch,  fur  Psychiat.,  Bd.  VI.,  1876,  p.  765. 

*  Dejerine  and  (Joetz.  "Note  sur  un  cas  de  paralysie  ascendante  aigue."  Arch, 
de  Physiol.,  2^  S^rie,  Tome  III.,  1876,  p.  312. 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  907 

attest  the  competency  of  the  observers.  In  the  case  recorded  by 
Walford^  portions  of  the  cord  were  found  softened,  some  parts 
being  almost  diffluent;  extensive  disintegration  was  found  in 
the  grey  substance  of  the  cervical  region  by  Clarke^  in  the  case 
reported  by  Harley ;  and  Baumgarten'  found  evidences  of  mye- 
litis in  the  case  which  came  under  his  observation,  along  with  a 
microphyte  in  the  blood.  Dejerine  and  Goetz  state  that  they 
observed  changes  in  the  anterior  roots  of  the  nerves.  The 
altered  fibres  presented  the  ordinary  characteristics  of  parenchy- 
matous neuritis  or  degenerative  atrophy,  such  as  are  observed 
in  the  peripheral  segment  of  a  nerve  after  section.  The  changes 
of  the  nerve  fibres  are  regarded  by  Ddjerine*  as  being  secondary  to 
alterations  of  the  motor  ganglion  cells  of  the  spinal  cord,  although 
the  latter  are  not  such  as  can  be  detected  with  the  microscope. 
In  the  case  reported  by  Velden,  the  autopsy  which  was  conducted 
by  Friedlander  gave  on  the  whole  negative  results  to  naked 
eye  examination.  The  s-pinal  cord  after  hardening  was  examined 
microscopically  by  Professor  Leyden.^  He  found  the  cord  un- 
usually thick  as  a  whole,  especially  the  cervical  enlargement ; 
the  vessels  were  surrounded  by  a  fluid  exudation ;  the  ganglion 
cells  were  swollen ;  and  the  nerve  fibres,  especially  the  axis 
cylinders,  were  swollen  at  certain  points,  and  reduced  in  size  at 
others,  these  changes  having  in  some  spots  proceeded  so  far  as 
to  have  produced  small  foci  of  softening.  The  appearances 
observed  corresponded  pretty  accurately  to  those  found  by 
Hayem  and  Hamilton  in  cases  of  acute  myelitis,  and  which  will 
be  subsequently  described.  The  nerve  trunks  did  not  reveal  any 
decided  changes. 

The  following  case  appears  to  me  to  have  been  an  example 
of  Landry's  paralysis;  but,  as  I  did  not  see  the  patient  during 
life,  the  diagnosis  must,  perhaps,  be  regarded  as  somewhat  doubt- 
ful.    The  symptoms  were  reported  to  me  by  Mr.  Wartenburg, 

*  Walford.     Association  Medical  Journal     1853.     p.  993. 

*  Harley  and  Clarke  (L. ).  Fatal  case  of  acute  progressive  paralysis.  The 
Lancet,  Vol.  II.,  1868,  p.  451.  See  also  Petitfils.  Considerations  sur  I'atrophie 
aigue  des  cellules  motrices.  1873. 

'  Baumgarten.  "Ein  eigenthiimliclier  Fall  von  Paralysie  ascendante  aigue  mit 
Pilzbildung  im  Blut."    Arch.  f.  Heilkunde,  Bd.  XVII. ,  1876,  p.  245. 

*  Dejerine.  Recherches  sur  les  lesions  du  systeme  nerveux  dans  la  paralysie 
ascendante  aigue.     1879.     p.  64. 

*  Velden  und  Leyden.    Loc.  cit.,  p.  336. 


908 


SYSTEM  DISEASES   OF  THE 


who  was  the  House  Surgeon  at  the  Royal  Infirmary,  and  who 
took  charge  of  the  case  in  the  absence  of  the  House  Physician: — 

Case  I. — Henrietta  E ,  set.  twenty-one  years,  was  admitted  into  the 

Eoyal  Infirmary,  under  the  care  of  Dr.  Browne,  on  January  26th,  1877,  and 
died  the  following  day.  On  admission  the  lower  extremities  were  completely 
paralysed,  and  there  was  partial  paralysis  of  the  upper  extremities.  The 
paralysis  of  the  upper  extremities  became  rapidly  more  pronounced,  the 
respiratory  muscles  were  soon  implicated,  and  the  patient  died  from 
asphyxia  about  thirty  hours  after  admission.  No  sensory  disturbances, 
oculo-pupUlary  phenomena,  vesical  troubles,  or  bed-sores  were  noted.  The 
history  obtained  on  admission  was  that  the  patient  had  had  a  slight  blow 
on  the  back  of  the  neck  fom*  days  previously,  and  that  she  soon  afterwards 
became  paralysed  in  the  lower  extremities.  There  were  no  contusions  or 
other  signs  of  injury. 

The  autopsy  was  conducted  by  me  thirty-six  hours  after  death,  and  the 
following  is  an  abstract  of  the  report:  Three  linear  and  deep  cicatrices 
are  observed  in  the  left  groin.  The  skin  over  the  sacrum  and  trochanters 
is  not  ulcerated ;  the  muscles  are  plump,  and  none  of  them  present  any 


Fig.  194. 


Fig.  194  (Young).  Section  of  the  Upper  Dorsal  Region  of  the  Spinal  Cord,  from  a 
case  of  Acute  Ascending  Paralysis.— A,  Anterior  horns  ;  P,  posterior  horns  ;  cc, 
central  canal ;  re,  vesicular  column  of  Clarke  ;  i,  internal ;  al,  antero-lateral ; 
pi,  postero-lateral  group  of  cells;  ml,  the  medio-lateral  area.  The  diseased 
portion  is  represented  by  the  lightly-shaded  area  which  occupies  the  central  grey 
column  and  its  extensions  between  the  antero-lateral  and  postero-lateral  groups, 
and  between  the  internal  and  antero-lateral  groups. 


SPINAL  CORD  AND  MEDULLA   OBLONGATA. 


909 


signs  of  atrophy.  The  spinal  cord  was  somewhat  softer  than  usual  in  the 
lower  half  of  the  cervical  and  dorsal  regions,  and  in  the  lower  half  of  the 
lumbar  enlargement  and  conus  meduUaris,  the  remaining  portions  being 
normal.  The  other  morbid  appearances  noted  were  unimportant.  I  have 
repeatedly  examined  sections  of  the  spinal  cord,  and  always  found  the 
greater  portion  of  the  ganglion  cells  of  the  anterior  horns  so  beautifully 
defined  and  healthy  that  I  came  to  regard  the  cord  as  being  typically 
healthy.  I  observed  decided  pathological  changes  in  the  central  column,  but 
regarded  them  as  accidental,  or  at  least  of  no  importance  so  far  as  tjie 
functional  disturbances  present  during  life  were  concerned.  When,  how- 
ever, embryological  considerations  forced  upon  me  the  conclusion  that  the 
central  columns  were  endowed  with  important  functions,  my  judgment  of 
the  significance  of  the  morbid  changes  observed  in  this  cord  became  altered. 
A  section  of  the  dorsal  region  is  represented  in  Fig.  194;  the  internal, 
antero-lateral,  and  postero-lateral  groups  are  normal,  while  the  central 
column  and  medio-lateral  area  are  diseased.  A  section  of  the  middle  of  the 
cervical  enlargement  is  represented  in  Fig.  195  ;  the  internal,  antero- 
lateral, and  postero-lateral  groups  are  normal,  while  the  central  column,  the 
median  area,  and  the  central  group  of  ganglion  cells  are  diseased.     The 

Fig.  196. 


Fig.  195  (Young).  Section  of  the  Middle  of  the  Cervical  Enlargement  of  the  Spinal 
Cord,  from  a  case  of  Acute  Ascending  Paralysis. — c,  Central  group,  and  a,  anterior 
group  of  ganglion  cells ;  m,  median  area.  The  remaining  letters  indicate  the 
same  as  the  corresponding  letters  in  Fig.  194.  The  diseased  area  is  represented 
by  the  lightly-shaded  portion  which  represents  the  central  grey  column  and  its 
extensions  into  the  median  area  (m),  between  the  anterolateral  and  postero- 
lateral groups  of  cells,  and  round  the  central  group. 


910  SYSTEM  DISEASES  OF  THE 

diseased  areas  showed  granular  degeneration  of  Gerlach's  nerve  network, 
complete  disappearance  of  the  ganglion  cells,  increase  of  nuclei,  and  dilata- 
tion and  congestion  of  blood-vessels. 

The  following  observation  renders  me  still  less  inclined  to  re- 
gard the  case  just  reported  as  a  genuine  example  of  the  disease: — 
In  the  summer  of  1882  Dr.  Steell  asked  me  to  see  a  patient, 
who  had  just  been  admitted  into  the  Royal  Infirmary,  under  the 
care  of  my  colleague,  Dr.  Roberts.  The  patient  was  a  woman, 
aged  forty-five  years,  who  was  suffering  from  paralysis  of  the 
lower  extremities  which  had  supervened  somewhat  suddenly 
about  ten  days  previously  to  my  seeing  her.  The  patient  lay  on 
her  back  in  bed  with  her  legs  extended;  the  muscles  of  the 
lower  extremities  were  relaxed,  passive  movements  of  them  did 
not  provoke  muscular  tension,  the  patellar-tendon  reactions  were 
absent  on  both  sides,  and  all  the  muscles  reacted  to  a  feeble  faradic 
current.  The  cutaneous  sensibility  was  normal,  but  deep  pressure 
over  the  muscles  caused  pain.  There  were  no  disturbances  of 
the  functions  of  the  bladder  or  rectum.  I  had  no  opportunity  of 
seeing  the  patient  again,  but  she  died  somewhat  suddenly  two 
days  afterwards.  The  post-mortem  examination  was  conducted  by 
Mr.  A.  H.  Young,  but  nothing  to  account  for  death  was  discovered 
in  any  of  the  organs  of  the  body,  and  the  spinal  cord  with  its 
membranes  appeared  quite  healthy  to  the  naked  eye.  Mr.  Young 
and  myself  have  since  examined  the  cord  microscopically,  but 
neither  of  us  have  detected  the  slightest  trace  of  disease  in  it. 

§  403.  Morbid  Physiology. — The  pathology  of  this  affection 
is  exceedingly  obscure,  and  Westphal  considers  it  probable  that 
the  disease  is  due  to  some  intoxication,  and  a  similar  opinion  had 
been  maintained  by  Landry.  In  many  respects  this  disease  is 
like  tetanus.  Acute  ascending  paralysis  manifests  itself  by  loss 
of  motor  power,  while  tetanus  is  manifested  by  symptoms  of 
motor  irritation,  but  both  affections  are  similar  in  their  mode  of 
invasion,  rapid  course,  and  frequently  rapid  fatal  termination. 

§  404.  Diagnosis. — It  may  not  be  possible  to  arrive  at  a 
positive  diagnosis  during  the  first  days  of  the  disease,  but  when 
it  is  fully  developed  the  diagnosis  presents  no  difficulty. 

Acute  anterior  poliomyelitis,  may  be  distinguished  from  this 


SPINAL  CORD  AND   MEDULLA  OBLONGATA.  911 

affection  by  the  facts  that  it  has  no  progressive  character,  rarely 
attacks  the  medulla,  and  hardly  ever  directly  causes  death.  It  is 
also  ushered  in  by  fever,  the  muscles  undergo  rapid  atrophy 
and  lose  their  faradic  excitability.  Even  the  temporary  form  of 
acute  anterior  myelitis  may  be  distinguished  from  acute  ascend- 
ing paralysis  by  the  rapid  lowering  of  the  faradic  excitability, 
and  by  the  fact  that  the  paralysis  is  not  progressive. 

Subacute  anterior  poliomyelitis,  when  it  pursues  a  tolerably 
rapid  ascending  course,  may  very  readily  be  mistaken  for  acute 
ascending  paralysis,  but  in  the  former  disease  the  muscles 
undergo  atrophy,  the  reaction  of  degeneration  is  present,  reflex 
action  is  abolished  at  an  early  period,  there  is  almost  entire 
absence  of  disturbances  of  sensibility,  bulbar  symptoms  only 
appear  at  a  late  period,  and  the  disease  is  never  so  rapidly  fatal 
as  Landry's  paralysis. 

In  acute  central  myelitis  there  is  always  a  high  degree  of 
disturbances  of  sensibility,  reflex  action  is  early  abolished,  the 
sphincters  are  paralysed,  and  there  are  fever,  acute  bedsores,  a 
lowering  of  faradic  excitability,  and  a  rapidly  fatal  termination. 

Acute  multiple  neuritis  may  be  distinguished  from  acute 
ascending  paralysis  by  the  severe  pains  limited  to  single  nerve- 
roots,  by  the  limitation  of  the  anaesthesia  and  paralysis,  and  by 
the  rapid  lowering  of  electrical  excitability. 

Hysterical  paraplegia  generally  simulates  the  spasmodic 
paralyses,  but  Landry's  paralysis  may  be  readily  mistaken^  for 
those  hysterical  cases  in  which  the  muscles  remain  flaccid.  It  is 
probable  that,  in  addition  to  the  general  symptoms,  the  absence 
or  presence  of  the  patellar-tendon  reactions  will  be  found  the 
most  valuable  diagnostic  sign  between  them. 

§  405.  Prognosis. — The  prognosis  is  always  serious.  The 
more  rapid  the  ascending  course  of  the  disease,  the  earlier 
respiration  has  been  attacked,  and  the  more  pronounced  the 
signs  of  bulbar  paralysis,  the  graver  does  the  prognosis  become. 
Out  of  the  ten  cases  mentioned  by  Landry,  five  only  of  which 
came  under  his  own  observation,  there  were  eight  recoveries,  but 
the  prognosis  does  not  appear  to  be  usually  so  favourable  as  these 

'  See  Finney  f  J.  M.).  "  Notes  of  a  case  of  acute  ascending  paralysis."  The 
Eritish  Medical  Journal,  Vol.  I.,  1882,  p.  732. 


912  SYSTEM  DISEASES   OF  THE 

figures  represent.  When  once  the  progress  of  the  disease  is 
arrested  and  improvement  begins,  the  prognosis  becomes  more 
hopeful,  but  even  then  there  is  danger  of  a  relapse. 

§  406.  Treatment. — At  an  early  stage  of  the  affection  Chap- 
man's ice-bag  may  be  applied  to  the  spine.  The  constant 
current  has  been  employed  in  the  later  stages  of  the  cases  which 
have  terminated  favourably.  If  syphilis  is  suspected  as  being 
the  cause  of  the  disease,  the  patient  must  be  treated  with  large 
doses  of  iodide  of  potassium,  and  a  subsequent  mercurial  course. 

(3)   Poliomyelitis  Anterior  Chronica  (Chronic  Atrophic 
Spinal  Paralysis). 

§  407.  Definition. — Chronic  atrophic  spinal  paralysis  of  adults 
presents  itself  as  a  motor  paralysis  associated  with  muscular 
atrophy,  which  begins  in  the  lower  extremities,  and  gradually 
progresses  upwards  until  the  muscles  of  the  trunk  and  upward 
extremities  are  involved.  The  affection  may  terminate  in  death 
from  respiratory  paralysis,  or  in  gradual  recovery,  the  motor 
power  returning  in  the  reverse  order  to  that  in  which  it  was  lost. 

History. — Duchenne^  first  described  this  affection  in  1849,  then  in 
1852,  and  he  gave  a  detailed  description  of  it  in  the  third  edition  of  his 
Electrisation  Localisee  in  1872.  He  beheved  on  theoretical  grounds  that 
the  disease  consisted  in  chronic  degeneration  of  the  grey  anterior  horns, 
and  consequently  he  designated  it  "  Paralysie  g^nerale  spinale  ant^rieure 
subaigue."  Single  instances  of  the  disease  have  since  been  described  by 
various  authors,  such  as  Pochd,^  Frey,^  Erb,*  Webber,^  Cornil  and  Le'pine,® 
Klose,'^  Goltdammer,^  Bernhardt,'  and  others. 

•  Duchenne.  Comptes  rendus  de  I'Acad.  de  Sc,  1849;  and  L'Elecfcriaation 
localisee,  3  Edit.,  1872,  p.  459. 

"^  Poch^.  Quelques  considerations  sur  les  amyotrophies  d'origine  spinale.  Th^se 
de  Paris,  1874. 

'  Frey.  "Fall  von  subacuter  Lahmung  Erwachsener — wabrscheinlich  Polio- 
myelitis anterior  subacuta."    Berl.  klin.  Wochenschr.,  Bd.  XI.,  1874,  pp.  549  u.  566. 

■*  Erb.  "Ueber  acut  Spinallahmung  bei  Erwachsener  und  iiber  verwandte 
spinale  Erkrankiing."    Arch.  f.  Psychiat.,  Bd.  V.,  1875,  Obs.  7,  p.  758. 

*  Webber.  "Contributiontothe  study  of  myelitis."  Transactions  of  the  American 
Neurological  Association  for  1875,  Vol.  I.,  p.  55. 

'  Cornil  et  licpine.  "  Cas'de  paralysie  g^n^rale  spinal  anterieur  subaigue,  suivi 
d'autopsie."    Gaz.  med.  de  Par.,  1875,  Nr.  11. 

'  Klose.  Beitrage  zur  Lehre  von  der  Paralys.  spinal,  anter.  subacut.  Diss. 
Breslau,  1876. 

®  Goltdammer.  "Ueber  einige  Falle  von  subacuter  Spinalparalyse."  Berl.  klin. 
Wochenschr.,  Bd.  XIII.,  1876,  p.  353. 

^Bernhardt.  "Beitrage  zur  Lehre  von  der  acute  atrophischen  Lahmung 
Erwachsener."    Arch.  f.  Psychiat.,  Bd.  VII.,  1877,  p.  313. 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  913 

§  408.  Etiology. — The  causes  of  this  disease  are  exceedingly 
obscure.  All  the  cases  which  have  been  observed  occurred  in 
adults  between  the  ages  of  thirty  and  fifty  years. 

Amongst  the  exciting  causes  the  most  frequent  are  traumatic 
injuries,  such  as  a  fall  on  the  back  or  hip,  exposure  to  severe 
cold,  damp  dwellings,  and  alcoholic  and  sexual  excesses.  Chronic 
lead  poisoning  leads  to  a  condition  very  similar  to  chronic 
atrophic  spinal  paralysis. 

§  409.  Symptoms. — The  disease  usually  begins  with  a  feeling 
of  lassitude  and  fatigue  in  walking,  pain  and  stiffness  in  the  loins 
and  lower  extremities,  slight  fever,  gastric  disturbances,  and 
headache,  while  the  patient  may  complain  of  various  parsesthesise, 
such  as  tingling  and  formication  of  the  feet  and  hands.  After  a 
time  distinct  muscular  weakness  is  felt  in  one  or  both  lower 
extremities,  which  gradually  increases  until  complete  paralysis 
of  certain  groups  of  muscles  or  of  the  entire  extremity  is 
established.  The  muscles  which  flex  the  foot  at  the  ankle  are 
the  first  to  become  affected,  and  subsequently  those  of  the  calf, 
the  flexors  of  the  thigh  on  the  trunk,  the  flexors  and  extensors 
of  the  leg  on  the  thigh,  and  the  extensors  of  the  thigh  upon  the 
body  become  successively  invaded.  The  disease  gradually 
pursues  its  ascending  progress,  and  the  upper  extremities 
become  implicated.  The  paralysis  sometimes  begins  in  the 
intrinsic  muscles  of  the  hand  and  the  flexors  of  the  fingers  and 
hand,  and  at  other  times  in  the  extensors  of  the  forearm,  and 
after  a  time  the  muscles  of  the  upper  arm  and  shoulder  become 
affected.  The  muscles  of  the  back  and  abdomen  are  also  para- 
lysed ;  the  patient  can  no  longer  raise  himself  in  bed  or  sit  up 
without  support,  and  expiratory  acts,  such  as  coughing  and 
sneezing,  as  well  as  defecation  and  urination  are  rendered  difficult 
and  ineffective.  When  the  intercostal  muscles  are  invaded  the 
breathing  becomes  wholly  abdominal,  being  carried  on  by  the 
contraction  of  the  diaphragm.  But  although  this  disease  usually 
begins  in  the  lower  extremities  and  follows  an  ascending  march, 
it  sometimes  begins  in  the  upper  extremities  and  pursues  a 
descending  course,  or  rather,  it  then  pursues  both  an  ascending 
and  a  descending  course,  inasmuch  as  the  paralysis  is  very  apt  to 
invade  not  the  lower  extremities  alone,  but  the  muscles  supplied 

VOL.  L  GGG 


914  SYSTEM  DISEASES  OF  THE 

by  the  bulbar  nuclei  also.  Altbougb  the  two  lower  and  the  two 
upper  extremities  are  usually  affected,  the  paralysis  is  frequently 
more  pronounced  on  one  side  of  the  body  than  on  the  other. 
The  paralysed  muscles  are  soft  and  flaccid,  no  muscular  tension 
is  provoked  in  them  on  passive  movements  of  the  affected 
extremities,  and  they  undergo  rapid  atrophy.  The  calves  of  the 
legs  become  converted  into  loose  and  flabby  sacks,  the  muscles 
of  the  thighs  and  gluteal  regions  grow  thin  and  soft,  and  the  bones 
of  the  lower  extremities  may  ultimately  be  felt  immediately 
underlying  the  skin,  while  scarcely  a  trace  of  their  muscular 
masses  are  left.  The  patient  now  lies  on  his  back  with  the 
various  segments  of  the  lower  extremities  extended  upon  one 
another ;  the  arms  lie  immovable  by  his  side  or  in  any  position 
in  which  they  may  be  placed ;  the  arms  and  forearms  become 
greatly  emaciated  from  disappearance  of  their  muscular  masses  ; 
the  thenar  and  hypothenar  eminences  are  flattened;  and  the 
hands  assume  characteristically  distorted  positions. 

Fibrillary  contractions  may  be  present  in  the  early  stages  of 
the  atrophy,  but  these  soon  disappear.  Reflex  action  is  lost  at 
an  early  period  of  the  disease,  and  the  tendon  reactions  are  like- 
wise soon  abolished. 

The  electrical  reactions  of  the  paralysed  nerves  and  nxuscles  are 
on  the  whole  the  same  as  those  observed  in  acute  atrophic  spinal 
paralysis,  being  only  modified  to  some  extent  in  correspondence 
with  the  slow  development  of  the  former  disease  as  compared 
with  the  latter.  The  faradic  contractility  of  the  muscles  was 
found  by  Duchenne  to  be  diminished- at  an  early  period  of  the 
disease  and  to  be  soon  entirely  lost,  while  in  a  case  observed  by 
Erb  the  nerves  did  not  respond  to  either  the  faradic  or  galvanic 
current,  and  the  muscles  manifested  the  typical  reaction  of 
degeneration. 

The  patient  may  complain  of  tingling  and  formication  of  the 
feet  and  hands,  but  every  form  of  cutaneous  sensibility  is  found 
normal  on  objective  examination,  and  the  position  in  which  the 
limbs  may  be  placed  by  passive  movements  of  them  is  recog- 
nised by  the  patient  without  the  aid  of  sight.  The  skin  of  the 
paralysed  limbs  may  become  of  a  blue  colour,  and  the  surface 
may  be  cold,  while  the  lower  extremities  are  sometimes 
cedematous,  but  there  are  no  bed-sores  or  cutaneous  eruptions, 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  915 

the  functions  of  the  bladder,  rectum,  sexual  organs  remain  un- 
aflfected,  and  the  general  health  is  satisfactory. 

§  410.  Course,  Duration,  and  Terminations. — The  rapidity 
with  which  the  paralysis  takes  place  varies  greatly  in  different 
cases.  When  the  lower  extremities  are  the  first  to  be  affected 
decided  paralysis  may  sometimes  be  preceded  by  symptoms  of 
weakness  and  heaviness  of  the  limbs,  while  at  other  times  the 
paralytic  phenomena  supervene  somewhat  suddenly.  The  rapidity 
with  which  the  disease  pursues  its  ascending  course  is  also  some- 
what variable  ;  the  paralysis  implicates  the  upper  extremities  in 
some  cases  a  few  weeks  from  the  onset  of  the  affection,  while  in 
other  cases  they  are  not  attacked  until  after  the  lapse  of  many 
months  or  years.  If  the  paralysis  is  not  arrested  in  its  ascending 
course  the  muscles  supplied  by  the  bulbar  nuclei  become  affected, 
and  the  patient  suffers  from  difficulty  of  articulation  and  deglu- 
tition, and  respiratory  troubles,  and  soon  dies  from  asphyxia  or 
syncope,  but  in  some  cases  death  may  take  place  from  simple 
exhaustion.  Very  frequently,  however,  the  disease  becomes 
arrested  in  its  ascending  course,  and  gradual  improvement  takes 
place. 

During  recovery  the  electrical  excitability  returns  to  the  normal 
standard  only  very  slowly  and  gradually.  The  further  course  of 
the  disease  is  somewhat  variable.  In  the  majority  of  cases  the 
paralytic  symptoms  remain  stationary  for  a  time ;  although  the 
muscular  atrophy  may  continue  to  advance  to  some  extent  and 
moderate  "  paralytic  contractions  "  to  be  developed.  After  some 
weeks  or  months  gradual  improvement  sets  in,  which  begins  in 
the  arms  and  hands,  and  as  it  advances  from  muscle  to  muscle 
their  galvanic  excitability  sinks  more  and  more,  and  slowly  gives 
place  to  the  normal  reaction,  while  the  distorted  positions  of  the 
hands  also  gradually  disappear. 

Recovery  is  so  slow  that  it  is  only  after  the  lapse  of  months 
that  the  patients  can  feed  themselves  and  perform  other  actions 
with  their  hands.  The  improvement  extends  after  a  time  to  the 
lower  extremities,  the  movements  of  the  hip-joint  first  becoming 
more  powerful  than  those  of  the  knee-joint,  and  last  of  all  those 
of  the  foot  and  toes,  until  ultimately  recovery  may  be  complete. 
More  frequently,  however,  the  recovery  is  incomplete.     Certain 


916  SYSTEM  DISEASES  OF  THE 

sets  of  muscles,  especially  those  in  the  region  of  distribution  of 
the  peroneal  nerve,  remain  paralysed  and  wasted,  so  that  the 
patient  is  partially  disabled  for  life. 

The  following  instance  of  the  disease  deserves  to  be  recorded 
at  length  on  account  of  the  long  period  of  time  which  elapsed 
between  the  onset  of  the  paralysis  and  the  loss  of  the  faradic 
contractility  of  the  aflfected  muscles.  The  notes  were  taken  by 
Mr.  Beverley,  one  of  the  House  Physicians  to  the  Infirmary,  and 
my  thanks  are  due  to  my  colleague,  Dr.  Morgan,  under  whose 
care  the  patient  is,  for  kindly  permitting  me  to  make  use  of 
the  case : — 

Case  II. — Harriet  L ,  aged  forty-four  years,  was  admitted  into  the 

Manchester  Eoyal  Infirmary  on  December  1st,  1882,  mider  the  care  of 
Dr.  Morgan. 

The  patient  has  been  married  for  ten  years,  and  has  had  two  children, 
both  of  whom  are  Hving  and  healthy;  she  has  not  had  a  miscarriage. 
She  has  been  Hable  to  sore  throat  on  exposure  to  cold,  and  her  hair  fell  off 
one  side  of  her  head  twenty  years  ago,  but  she  has  a  fair  quantity  of  hair  at 
present,  and  has  never  been  subject  to  cutaneous  eruptions.  Her  father 
died  from  cancer,  and  her  mother  from  some  disease  of  the  lungs,  but  there 
does  not  appear  to  be  any  family  predisposition  to  nervovis  disease.  The 
patient's  countenance  is  red  and  somewhat  bloated,  but  she  denies  ever 
taking  an  excess  of  alcohol  in  any  form,  although  she  admits  to  having 
taken  "  half  a  noggin  of  whisky  "  occasionally  since  her  illness  began.  She 
has  always  had  sufficient  food  and  been  well  clothed,  and  does  not  appear  to 
have  been  unduly  exposed  to  damp  and  cold.  The  patient  has  always  enjoyed 
excellent  health  until  about  six  months  ago;  at  that  time  she  ceased 
menstruating,  and  complained  of  a  feeling  of  cold  water  running  down  her 
arms  and  legs.  At  this  time  her  right  leg  became  swollen,  but  the  swelling 
subsided  in  two  or  three  days.  A  few  days  later  she  felt  her  legs  heavy 
and  weak,  and  within  a  week  the  lower  extremities  became  so  much  paralysed 
that  she  was  quite  unable  to  walk,  and  when  she  was  assisted  to  the  erect 
posture  her  legs  doubled  up  imder  her  in  a  perfectly  helpless  manner.  Soon 
afterwards  her  arms  felt  heavy,  but  for  two  or  three  weeks  longer  she  could 
sew,  and  was  able  to  perform  some  manual  operations  for  a  still  longer 
period,  but  during  the  four  weeks  before  admission  she  has  been  completely 
helpless,  being  quite  unable  to  use  her  hands  for  any  purpose  whatever. 
Dining  the  whole  of  this  time  she  has  not  suffered  from  any  pain,  her 
bowels  have  been  constipated,  but  she  has  had  no  dribbling  of  urine,  and  no 
difficulty  in  passing  it. 

Present  Condition. — The  patient  is  of  a  cheerful  disposition,  and  has  a 
healthy  appearance.  A  network  of  dilated  veins  is  seen  over  the  malar 
prominences,  and  the  arteries  generally  show  some  signs  of  degeneration  ; 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  917 

but  the  general  liealtli  is  good ;  the  tongue  is  moist  and  clean  ;  the  internal 
organs  are  healthy ;  and  the  temperature  is  normal.  She  hes  on  her  back, 
and  is  unable  to  turn  over  in  bed  or  to  help  herself  in  the  slightest 
with  her  hanrls.  The  power  of  producing  dorsal  flexion  of  the  foot  is  absent 
on  both  sides;  the  toes  can  be  moved  sHghtly  and  feebly,  and  the  patient 
can  produce  feeble  contractions  of  the  muscles  of  the  calf  and  those  of  the 
thigh.  The  muscles  of  the  lower  extremities  are  not  decidedly  atrophied, 
but  they  feel  flabby  and  flaccid,  and  no  tension  is  provoked  on  passive 
movements  of  the  Hmbs.  The  abdominal  walls  are  flaccid,  and  the  muscles 
only  contract  feebly  during  coughing  and  attempts  at  urination.  The 
intercostal  muscles  and  the  diaphragm  appear  to  act  normally.  When  the 
patient  is  raised  to  a  sitting  postiu-e  she  is  unable  to  maintain  the  position 
without  support,  and  the  erector  spinse  muscles  only  act  very  feebly.  The 
accessory  muscles  of  respiration  generally,  the  muscles  of  the  neck,  the 
pectoral  muscles,  and  the  inward  and  outward  rotators  seem  to  be  unafiected, 
but  the  latissimus  dorsi,  the  deltoid,  and  aU  the  muscles  of  the  arm, 
forearm,  and  hand  are  almost  completely  paralysed  on  both  sides.  The 
thenar  and  hypothenar  eminences  of  both  hands  are  decidedly  flattened, 
and  each  hand  has  assumed  the  form  of  a  claw. 

Active  reflex  actions  are  obtained  on  tickling  the  sole  of  the  foot,  but 
the  tendon-reactions  are  absent  at  the  knees,  the  elbows,  and  the  wrists. 

The  various  forms  of  cutaneous  sensibiUty  as  tested  pricking,  ticlding, 
touch,  separate  points,  and  heat  and  cold  are  everywhere  normal,  and  the 
patient  Hkewise  can  teU  the  position  of  her  limbs  when  they  are  pas- 
sively moved  whilst  her  eyes  are  closed. 

All  the  paralysed  muscles  with  their  nerves  react  readily  to  a  feeble 
faradic  ciurent,  the  reactions  being  considerably  in  excess  of  those  obtained 
from  healthy  muscles.  All  the  paralysed  muscles  also  contract  readily  to 
the  galvanic  current,  contractions  being  obtained  from  a  feebler  current 
with  cathodal  than  with  anodal  closure. 

January  28th :  A  few  days  after  admission  a  slight  bed-sore  appeared  on 
the  sacrum,  but  it  healed  up  in  a  few  days,  and  all  redness  of  the  skin  soon 
disappeared.  So  far  as  the  paralysis  is  concerned  the  condition  of  the 
patient  has  remained  nearly  imchanged,  except  that  the  affected  muscles  are 
more  atrophied  and  feebler  than  they  were  on  admission,  and  that  it  is 
noticed  that  the  paralysis  is  more  pronounced  on  the  left  than  on  the  right 
side  of  the  body.  The  reflex  of  the  sole  is  now  absent,  but  sHght  flexion  of 
the  thimibs  still  occurs  when  the  palms  of  the  hands  are  tickled.  A  great 
change  has,  however,  taken  place  in  the  electrical  reactions  of  the  paralysed 
muscles.  None  of  the  paralysed  muscles  now  contract  to  the  strongest 
faradic  current,  either  when  apphed  directly  or  through  the  nerves  which 
supply  them.  The  alteration  in  the  electrical  reactions  of  the  nerves  and 
muscles  was  observed  for  the  first  time  on  December  28th,  and  repeated 
examinations  since  that  time  have  led  to  the  same  uniform  results.  The 
reactions  of  the  extensors  of  the  forearm  and  of  the  peroneal  group  may  be 
taken  as  a  sample  of  those  of  the  remaining  paralysed  muscles. 


918  SYSTEM  DISEASES  OF  THE 

Extensors  of  Forearm. 
Right  Arm.  Left  Arm. 

25  cells  Ca  Sc  15  ceUs  Ca  So 

30    „     CaOo  20    „     CaOc 

15    „      ASc  15    „     ASc 

20    „     AOc  15     „     AOc 

Peroneal  Group  of  Muscles. 

Right  Leg.  Left  Leg. 

15  cells  CaSc  15  cells  Ca  Sc 

35    „  CaO-  30    „     C  0- 

15     „  ASc  10    „     ASc 

30    „  AO-  15    „    ' AOc 

February  12tli :  Since  the  last  report  several  noteworthy  changes 
have  occurred  in  the  condition  of  the  patient.  Ten  days  ago  all  the  small 
joints  of  both  hands  became  swollen,  red,  and  painful ;  the  patient  has 
perspired  somewhat  freely,  and  the  bed-clothes  have  a  sour  smell  resembhng 
that  of  acute  rheumatism.  The  pain  and  redness  have  now  subsided,  but 
the  joints  are  still  considerably  enlarged.  Simultaneously  with  the  onset  of 
the  attack  of  arthritis  an  amehoration  in  the  paralytic  symptoms  was 
observed,  and  since  that  time  there  has  been  a  gradual  but  steady  recovery 
of  motor  power  in  the  upper  extremities.  The  patient  can  now  raise  her 
arms  to  a  vertical  position,  she  can  move  the  forearms  freely  at  the  elbows, 
and  the  hands  at  the  wrist,  but  her  grasp  is  still  feeble,  and  the  thumb 
cannot  be  opposed  or  abducted  except  to  a  very  slight  extent.  All  the  muscles 
of  both  upper  extremities  now  react  to  a  weak  faradic  current,  including 
even  those  of  the  thenar  and  hypothenar  eminence,  although  they  are  yet 
so  much  wasted  that  the  metacarpal  bones  of  the  thumbs  and  Httle  fingers 
appear  to  lie  almost  directly  under  the  skin.  The  reactions  of  all  these 
muscles  to  the  galvanic  current  are  also  changed.  Speaking  broadly,  a 
minimum  contraction  is  obtained  to  25  cells  Leclanchd  both  on  cathodal  and 
anodal  closure,  the  contraction  to  the  former  being  rather  the  stronger  of 
the  two.  The  muscles  of  the  lower  extremities  have  remained  imchanged 
so  far  as  motor  power  is  concerned,  and  they  still  manifest  the  "  reaction 
of  degeneration." 

The  case  which  has  just  been  described  presented  many 
difficulties  in  diagnosis  on  her  admission  to  the  Infirmary. 
The  ready  response  of  all  the  paralysed  muscles  to  the  faradic 
current,  which  I  myself  had  witnessed,  rendered  it  difficult  to 
regard  the  case  as  one  of  chronic  atrophic  spinal  paralysis,  while 
its  protracted  course  as  compared  with  cases  of  Landry's  paralysis, 
and  its  sudden  onset  and  rapid  course  as  compared  with  cases  of 
progressive  muscular  atrophy,  rendered  it  equally  difficult  to 
place  it  in  either  of  these  categories.     Had  the  paralysis  impli- 


SPINAL   CORD  AND   MEDULLA  OBLONGATA.  919 

cated  the  bulbar  nuclei  and  caused  death  a  week  after  the 
patient's  admission  into  the  infirmary,  I  should  like  to  know  in 
what  category  would  the  disease  have  been  placed.  In  the 
following  case  this  dilemma  has  actually  occurred,  and  I  am  still 
unable  to  classify  the  case,  although  I  am  inclined  to  regard  it 
as  an  example  of  chronic  atrophic  spinal  paralysis.  The  notes 
of  the  case  were  taken  by  Mr.  Hayes,  House  Physician  to  the 
Infirmary,  and  by  Mr.  Williams,  my  clinical  clerk. 

Case   III. — William  H ,  aged  twenty-seven  years,  labourer,  was 

admitted  into  the  Eoyal  Infirmary  on  March  21st,  1882,  under  the  care  of 
Dr.  Ross. 

The  patient's  parents  are  both  living,  and  have  enjoyed  good  health 
imtil  recently,  when  his  mother  has  suffered  from  dropsy.  He  is  mar- 
ried, and  has  one  child.  His  wife  is  healthy,  and  has  not  had  mis- 
carriages. The  patient  has  been  exposed  to  cold  and  wet,  but  the  house 
in  which  he  resides  is  in  a  dry  situation,  and  he  has  never  suffered  from 
deficiency  of  food  or  clothing.  He  has  been  very  temperate,  and,  with  the 
exception  of  a  slight  attack  of  rhemnatism  from  which  he  suffered  eight 
years  ago,  he  has  never  had  any  illness  up  to  the  beginning  of  his  present 
attack.  About  the  beginning  of  December  last,  the  patient  suffered  from 
considerable  pain  about  the  region  of  the  stomach,  which  was  regarded  at 
the  time  as  being  due  to  indigestion,  but  he  had  no  vomiting.  About  this 
time  he  felt  some  difficulty  in  raising  his  right  hand  to  his  head,  and  a  very 
short  walk  sufficed  to  cause  so  much  fatigue  that  his  knees  knocked 
against  each  other,  and  his  legs  bent  under  him.  His  right  arm  became 
day  by  day  feebler  and  feebler,  the  weakness  now  extended  to  the  left  arm, 
and  the  lower  extremities  became  so  feeble  that  the  patient  was  unable  to 
stand.  He  also  states  that  his  voice  became  altered,  and  that  he  expe- 
rienced some  difficulty  in  pronouncing  long  words. 

Present  Condition.  —The  patient  has  afresh  and  healthy  appearance,  but 
he  is  unable  to  stand,  or  even  to  maintain  a  sitting  posture  without  being 
propped  up.  As  he  lies  in  bed  his  lower  extremities  are  extended,  the  feet 
are  maintained  in  the  position  of  moderate  talipes  equino-varus ;  there  is 
hyperextension  of  the  toes  at  the  metatarso-phalangeal  joints  arid  flexion  of 
them  at  the  phalangeal  joints.  The  patient  can  perform  all  the  separate 
movements  with  the  lower  extremities,  although  the  execution  of  all  move- 
ments is  slow  and  feeble,  the  right  being  decidedly  more  feeble  than  the 
left  leg.  The  muscles  of  the  right  lower  extremity  are  also  somewhat 
wasted,  as  compared  with  those  of  the  left.  The  circumference  of  the 
right  thigh  at  the  junction  of  the  upper  and  middle  thirds  is  14^  inches, 
and  of  the  left  14| ;  and  that  of  the  right  calf  is  lOj  inches,  and  of  the 
left  11  inches. 

The  muscles  of  the  lower  extremities  offer  a  slight  degree  of  resistance 
to  passive  movements  of  the  hmbs,  the  tension  being  more  marked  on  the 


920  SYSTEM  DISEASES  OF  THE 

left  tlian  right  side.  The  reflex  of  the  sole  is  exaggerated  on  both  sides, 
and  the  cremasteric,  abdominal,  and  epigastric  reflexes  are  very  lively, 
probably  exaggerated.  No  distinct  ankle  clonus  can  be  elicited  on  either 
side,  but  the  patellar-tendon  reactions  are  exaggerated,  that  of  the  right 
being  nearly  as  lively  as  that  of  the  left.  The  most  careful  examination 
failed  to  detect  disorder  of  any  form  of  sensibiUty.  All  the  muscles  of  the 
lower  extremity  reacted  to  a  moderate  faradic  current,  and  the  galvanic 
reactions  did  not  manifest  any  qualitative  changes.  The  right  upper  arm 
usually  lies  by  the  side  of  the  patient ;  the  forearm  is  bent  at  right  angles 
to  the  upper  arm  and  crossed  over  the  body,  the  hand  and  fingers  assuming 
the  usual  position  of  complete  rest.  The  patient  can  grasp  an  object,  but 
very  feebly  ;  he  can  also  perform  all  the  movements  of  the  fingers  and 
thumb,  and  at  the  wrist-joint.  Flexion  of  the  forearm  is  very  feeble,  while 
extension  of  it  is  somewhat  stronger.  The  movements  at  the  shoulder 
joint  are  feebler  than  those  at  any  of  the  other  articulations,  and  abduction 
of  the  arm  is  impossible.  All  the  muscles  of  the  right  upper  extremity 
appear  to  be  more  or  less  atrophied,  but  the  wasting  is  more  marked  in  the 
deltoid,  biceps,  and  brachialis  anticus  than  in  the  other  muscles.  The 
various  segments  of  this  extremity  can  be  moved  passively  in  any  direction 
without  provoking  muscular  tension,  and  when  the  arm  is  drawn  away 
from  the  body  the  latissimus  dorsi  and  pectoral  muscles  do  not  enter  into 
contraction.  The  triceps  tendon  reaction  is  npt  readily  ehcited,  but  when  the 
lower  end  of  the  radius  and  the  tendon  of  the  supinator  longus  are  tapped, 
some  of  the  fibres  of  the  supinator  longus  and  of  the  biceps,  and  even  of 
the  deltoid,  may  be  seen  to  enter  into  contraction,  although  the  contrac- 
tions are  not  so  powerful  as  to  give  a  jerk  to  the  arm'.  The  left  upper 
extremity  is  affected  to  a  much  less  degree  than  the  right,  and  the  patient 
can  perform  all  the  various  movements  at  the  different  joints,  although  with 
diminished  power.  The  deltoid,  biceps,  and  supinator  longus  manifest 
some  degree  of  atrophy,  but  to  a  much  less  extent  than  the  corresponding 
muscles  on  the  right  side.  Passive  movements  of  the  left  upper  extremity 
provoke  some  degree  of  muscular  tension,  and  the  tendon  reactions  are 
distinctly  increased.  The  pectoral  muscles  on  both  sides  are  feeble  and 
atrophied,  the  disease  being  more  pronounced  on  the  right  than  the  left 
side.  The  faradic  contractility  of  the  atrophied  muscles  is  normal,  or  at 
least  not  much  diminished,  and  there  are  no  sensory  disturbances,  either 
in  the  upper  extremities  or  extending  in  a  belt  round  the  body  or  neck. 
When  the  patient  is  propped  up  in  bed,  it  is  seen  that  the  erector  spinse 
and  the  muscles  of  the  back  of  the  neck  are  feeble  and  atrophied.  The 
sterno-cleido-mastoids  and  the  other  muscles  of  the  front  of  the  neck  are 
not  affected  to  nearly  the  same  extent  as  those  of  the  back.  When 
the  patient's  head  is  unsupported  it  drops  forwards,  so  that  the  chin 
rests  on  the  sternum,  but  he  can  by  a  strong  effort  raise  the  head 
to  the  erect  posture,  but  can  only  maintain  it  in  this  position  for  a 
very  short  time;  during  this  time  the  head  is  agitated  by  a  slight 
tremor    caused    by    intermittent    contractions    of  the   muscles    of  the 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  921 

neck,  and  it  soon  drops  forward,  so  that  the  chin  rests  again  on  the 
sternum.  The  latissimus  dorsi,  serratus  magnus,  rhomboids,  trapezius 
levator  anguli  scapulae,  supraspinatus,  infraspinatus,  and  teres  major  and 
minor  are  all  feeble  and  atrophied,  and  on  the  right  side  these  muscles  are 
almost  completely  paralysed,  and  the  scapula  can  be  felt  lying  almost  under 
the  skin,  apparently  with  very  little  muscvdar  substance  intervening.  All 
the  atrophied  muscles  react  to  a  moderate  faradic  current.  The  inter- 
costal muscles  and  diaphragm  are  still  active,  and  the  abdominal  muscles 
can  be  contracted  by  a  voluntary  eflfort.  The  functions  of  the  bladder  and 
rectum  are  iminterfered  with.  The  facial  muscles  are  unaffected,  and  the 
patient  can  whistle,  blow  out  a  candle,  and  pronounce  aU  the  labial  con- 
sonants perfectly.  He  can  also  protrude  the  tongue,  roll  it  up  into  a 
tube,  tiu-n  the  tip  upwards  towards  the  nose,  move  it  laterally  with  appa- 
rently undiminished  force,  and  pronounce  perfectly  the  hngual  consonants. 
The  soft  palate  is  pendulous,  its  reflex  action  is  sluggish,  but  there  is  no 
distinct  paralysis  of  the  muscles.  The  pronunciation  of  the  letter  0  has  a 
somewhat  nasal  quality,  and  the  patient  has  some  difficulty  in  articulating 
some  polysyllabic  words.  He  is  himself  positive  in  his  statement  that  he 
experiences  some  difficulty  of  articulation,  but  deglutition  and  phonation 
are  unaffected. 

March  28th :  The  symptoms  have  not  changed  much  since  the  patient's 
admission,  but  he  complains  this  morning  of  not  feeling  so  well  as  he  had 
previously  done ;  he  experiences  a  feeling  of  tightness  across  his  chest, 
along  with  some  difficulty  of  breathing.  In  the  evening  his  temperature 
rose  to  100°  F. ;  the  difficulty  of  breathing  became  worse,  and  the  tightness 
across  the  chest  more  distressing.  He  remained  quite  conscious,  but  his 
voice  was  feeble,  and  he  declined  some  brandy  and  water  offered  to  him,  as 
he  felt  he  could  not  swallow.  He  rallied  somewhat  after  a  time,  but  had 
another  severe  attack  of  difficulty  of  breathing  at  six  o'clock  in  the 
morning. 

March  29th  :  The  patient  looks  pale  and  collapsed,  the  temperature  is 
96  "8°  F.,  and  the  pulse  is  very  feeble,  and  beats  from  140  to  150  in 
the  minute.  The  intercostal  muscles  are  completely  paralysed,  and  the 
breathing  is  wholly  diaphragmatic.  No  evidences  of  pneumonia  or  any 
other  disease  in  the  chest  could  be  detected  anteriorly,  but  the  patient 
was  too  ill  to  allow  of  an  examination  of  the  chest  posteriorly. 

The  patient  had  a  severe  attack  of  difficulty  of  breathing  in  the  after- 
noon, during  which  his  extremities  were  livid,  cold  and  clammy,  and  his 
body  was  bathed  in  a  profuse  perspiration.  After  this  attack  he  rallied  a 
little,  but  died  somewhat  suddenly  at  6-40  p.m. 

Post-mortem. — The  post-mortem  examination  was  conducted  by  Mr. 
A.  H.  Young  thirty  hours  after  death,  but  the  spinal  cord  was  alone 
removed,  as  no  permission  was  granted  to  open  the  rest  of  the  body.  The 
spinal  cord  with  its  membranes  appeared  perfectly  healthy  to  the  naked 
eye,  except  that  the  grey  substance  of  the  cervical  region  was  somewhat 
depressed  below  the  level  of  the  white  substance  on  transverse  section. 


922  SYSTEM  DISEASES  OF  THE 

A  microscopical  examination  of  sections  of  the  cord,  kindly  made  for  me  by 
Mr.  Young,  showed  that  the  ganglion  cells  of  the  anterior  horns  in  the 
cervical  region  had  almost  completely  disappeared,  the  largest  of  them 
being  only  represented  by  shrivelled  masses  destitute  of  processes,  each 
being  scarcely  a  third  the  size  of  a  healthy  cell.  Minor  changes  were 
observed  in  the  cells  of  the  dorsal  and  lumbar  regions,  but  these  changes 
were  not  weU  marked,  and  might  have  been  overlooked  vdthout  careful 
examination.  The  lateral  columns  were  normal  throughout  the  whole 
length  of  the  cord. 

The  case  which  has  just  been  described  presents,  as  already 
remarked,  considerable  difficulty  of  diagnosis,  and  I  am  even 
now  uncertain  whether  to  regard  it  as  an  example  of  Landry's 
paralysis  with  an  unusually  protracted  course,  of  progressive  mus- 
cular atrophy  with  unusually  rapid  course,  or  of  chronic  atrophic 
spinal  paralysis.  Of  these  three  alternatives  I  am  inclined  to 
adopt  the  latter,  inasmuch  as  the  morbid  changes  found  on  a 
microscopical  examination  of  the  spinal  cord  undoubtedly  point 
to  this  conclusion.  This  case  and  the  preceding  one,  however, 
show  that  these  three  diseases  are  connected  by  transitional  cases, 
and  that  the  electrical  examination  of  the  muscles  does  not  afford 
so  conclusive  a  diagnostic  sign  in  distinguishing  them  as  has 
hitherto  been  supposed. 

One  other  point  in  connection  with  the  last  case  is  worthy  of 
attention ;  although  the  muscles  of  the  lower  extremities  were 
paralysed,  and  some  of  them  had  undergone  a  certain  degree  of 
atrophy,  yet  no  recognisable  microscopical  changes  were  found 
in  the  lumbar  region  of  the  spinal  cord.  No  one  can  doubt  that 
the  paralysis  and  atrophy  of  the  muscles  of  the  lower  extremities 
was  caused  in  this  case  by  disease  in  the  grey  anterior  horns  of 
the  lumbar  region,  similar  to  that  of  which  such  very  decided 
evidences  were  discovered  in  the  cervical  region.  The  absence 
of  recognisable  changes  in  the  lumbar  region  in  this  case  shows 
that  a  lesion  may  exist  in  the  cord  sufficient  to  cause  muscular 
paralysis  and  atrophy,  but  of  which  no  traces  are  perceptible 
by  our  present  means  of  examination.  The  absence  of  recog- 
nisable changes  in  the  cord  in  cases  of  Landry's  paralysis  does 
not  therefore  prove  that  the  disease  is  not  a  spinal  one. 

The  following  case  is  recorded  in  full  because  the  symptoms 
showed  that  it  was  a  typical  example  of  chronic  atrophic  para- 
lysis, and  very  decided  changes  were  discovered  in  the  spinal 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  923 

cord  after  death.  The  notes  of  the  case  were  taken  by  Mr.  E,  L. 
Luckman,  who  was  House  Physician  to  the  Infirmary  at  the  time 
of  the  report : — 

Case  IV. — Eliza  R ,  aged  fifteen  years,  entered  tlie  Royal  Infirmary 

on  August  23rd,  1880,  under  the  care  of  Dr.  Ross. 

History. — She  has  been  weakly  from  infancy,  and  has  worked  in  the 
mill  in  a  hot  room  since  she  was  eleven  years  of  age.  About  six  months 
ago  her  work  caused  her  an  unwonted  amount  of  fatigue,  and  she  soon 
afterwards  noticed  that  there  was  distinct  loss  of  power  in  the  left  leg  and 
arm,  followed  after  a  brief  interval  of  time  by  weakness  of  the  left  leg. 
The  weakness  of  the  lower  extremities  gradually  increased,  so  that  in  two 
months  from  the  commencement  of  the  attack  she  was  compelled  to  leave 
off"  work.  She  states  that  she  has  been  unable  to  walk  for  the  last  three 
months,  but  it  was  found  that,  with  assistance,  she  could  make  a  few  steps, 
the  limbs  being,  as  it  were,  dragged  forward.  She  has  entire  control  over 
the  sphincters,  and  the  only  sensory  disturbances  complained  of  have  been 
"  springing  "  pains  in  both  legs. 

Present  Condition. — As  she  lies  in  bed  she  has  a  suffering,  anxious 
expression,  and  the  muscles  of  the  trunk  and  extremities  are  seen  to  be 
much  wasted.  The  upper  lips  are  dry  and  cracked,  the  teeth  are  covered 
with  sordes,  and  the  tongue  has  a  beef-steak  appearance. 

Left  arm  lies  by  the  side,  the  elbow  being  removed  two  inches  from  the 
body.  The  left  forearm  is  flexed  at  right  angles  to  the  upper  arm  ;  it  is 
strongly  pronated,  so  that  the  ulnar  side  of  the  hand  is  directed  upwards. 
The  hand  is  shghtly  extended  on  the  forearm,  the  first  phalanges  are  semi- 
flexed on  the  metacarpal  bones,  the  second  phalanges  are  semi-flexed  on 
the  first,  and  the  third  on  the  second.  The  muscles  of  the  ball  of  the 
thumb  are  decidedly  wasted,  and  those  of  the  hypothenar  eminence  are 
also  atrophied.  The  patient  cannot  produce  opposition  of  the  thumb, 
and  adduction  is  feeble.  The  metacarpal  bone  of  the  thumb  lies  on  a 
level  with  the  metacarpal  bone  of  the  index  finger.  The  first  phalanx  of 
the  thumb  is  extended  and  shghtly  abducted,  the  second  phalanx  being 
slightly  flexed  on  the  first.  The  general  position  of  the  right  arm  corre- 
sponds to  that  of  the  left.  Abduction  of  the  thumb  is,  however,  much 
more  powerfully  performed  on  the  right  side  than  on  the  left  side,  the 
fingers  of  both  hands  are  in  a  semi-closed  position,  the  index  and  middle 
less  closed  than  the  ring  and  little  fingers.  The  interossei  are  atrophied, 
causing  deep  grooves  to  appear  between  the  metacarpal  bones.  All  the 
movements  of  the  difierent  segments  of  the  right  arm  can  be  performed, 
but  supination  of  the  forearm  is  very  feeble,  and  can  only  be  effected  to  a 
position  midway  between  pronation  and  supination.  The  left  hand  lies 
powerless,  in  the  position  already  described,  and  can  be  moved  only  to  a 
slight  extent. 

The  lower  extremities  are  almost  completely  paralysed,  and  when  the 
patient  is  asked  to  move  them  only  a  slight  movement  occm's,  which  is 


924  SYSTEM  DISEASES  OF  THE 

effected  by  the  muscles  of  the  thigh.  The  anterior  muscles  of  the  calf  are 
quite  paralysed.  Both  feet  occupy  the  position  of  talipes  equinus ;  but 
the  deformity  can  be  readily  made  to  disappear  by  producing  passive  dorsal 
flexion  of  the  foot.  The  different  segments  of  the  lower  extremities  can 
be  readily  moved  upon  one  another,  the  muscles  are  flaccid,  and  there  is  a 
complete  absence  of  the  quadriceps  tendo-reflex  and  of  ankle  clonus. 
There  are  no  tremors  or  fibrillary  contractions  of  the  muscles  of  the  lower 
extremity,  but  a  few  fibrillary  contractions  are  occasionally  observed  in  the 
left  hypothenar  eminence.  The  patient  cannot. raise  herself  in  bed,  but  on 
being  asked  to  do  so  the  recti  muscles  of  the  abdomen  may  be  felt  to  con- 
tract slightly,  but  have  not  sufiicient  power  to  raise  the  body.  With  the 
exception  of  an  occasional  dribbling  of  urine,  the  functions  of  the  bladder 
and  rectum  are  normally  performed,  and  the  abdominal  muscles  contract 
sUghtly  during  the  acts  of  defecation  and  urination.  When  she  is  raised 
in  a  sitting  posture  she  cannot  hold  the  body  erect. 

At  the  onset  of  the  attack  she  had  some  "  springing  "  pains  in  the  lower 
extremities,  but  these  abnormal  sensations  have  now  disappeared.  She  can 
distinguish  two  points  touching  the  surface  of  the  outer  side  of  the  leg 
when  two  inches  apart. 

The  sense  of  temperature  is  very  accurate  and  that  of  touch  good. 
Every  form  of  sensibility  is,  indeed,  perfectly  normal  all  over  the  body. 

The  reflex  of  the  sole  of  the  foot,  the  gluteal,  abdominal,  epigastric, 
and  scapular  reflexes  are  absent. 

The  faradic  contractihty  of  the  affected  nerves  and  muscles  is  entirely 
abolished. 

The  galvanic  current,  applied  percutaneously,  obtains  no  response  from 
the  anterior  muscles  of  the  legs,  even  when  fifty  Leclanch^  cells  are  used. 

On  the  current  being  applied  by  electric  acupuncture,  the  muscles  of 
the  anterior  part  of  the  leg  contract  slightly  with  fifteen  cells  on  cathodal 
closure,  but  do  not  contract  on  anodal. 

When  the  galvanic  current  is  now  applied  after  the  needles  have  been 
removed,  the  anterior  muscles  of  the  leg  contract  distinctly  on  cathodal 
closure  with  fifty  cells. 

The  extensors  of  the  right  forearm  contract  slightly  on  cathodal  closure 
with  fifty  Leclanchd  cells,  but  give  no  reaction  on  anodal  closure. 

The  extensors  of  the  left  forearm  give  po  response  either  on  cathodal  or 
anodal  closure  or  opening  when  fifty  cells  are  used. 

The  treatment  consisted  of  the  stabile  application  of  the  constant 
current  to  the  spine  for  a  few  minutes  daily,  the  current  being  also  passed 
for  a  longer  period  daily  through  the  affected  nerves  and  muscles.  No 
sensible  alteration  took  place  in  her  condition  until  the  evening  of  Sep- 
tember 16th,  when  the  breathing  was  observed  to  be  embarrassed.  At 
three  o'clock  in  the  morning  the  hands  and  lips  were  livid  ;  the  eyes  were 
half  closed  ;  her  face  and  body  were  bathed  in  cold  perspiration  ;  the  voice 
was  weak ;  the  diaphragm  had  ceased  to  play,  respiration  consisting  chiefly 
of  an  elevation  movement,  and  could  not  be  made  to  contract  by  a  strong 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  925 

faradic  current  passed  through  the  phrenic  nerves.     She  seemed  to  rally  a 
little  for  a  short  time,  but  the  diaphragm  remained  paralysed. 

At  nine  a.m.,  September  17th,  the  surface  was  bathed  in  profuse  per- 
spiration ;  the  skin  was  cold  and  clammy,  the  temperature  being  97'6 ;  the 
lips  and  hands  were  livid  ;  and  the  pulse  was  feeble  and  quick,  beating  152 
in  the  minute ;  the  respirations  were  slow  and  inefifectual,  but  she  remained 
conscious  to  the  last,  and  died  at  eleven  a.m. 

Autopsy. — Immediately  after  death  the  body  was  placed  face  downwards, 
the  spine  was  covered  with  ice  until  the  post-mortem,  conducted  by  Dr. 
Alfred  Young,  in  the  evening.  No  changes  worth  recording  were  observed 
by  the  naked  eye  in  the  brain,  or  even  in  the  spinal  cord.  The  veins  over 
the  posterior  surface  of  the  lumbar  region  of  the  cord  were  greatly  distended. 
On  making  transverse  sections  of  the  spinal  cord  at  intervals  of  a  quarter 
of  an  inch  from  above  downwards,  it  was  observed  that  definite  areas  of  the 
white  substance  were  of  a  grey  colour  and  gelatinous  appearance.  The 
grey  substance  of  the  central  columns  and  anterior  horns  from  the  fifth  or 
sixth  cervical  nerves  downwards  was  depressed  below  the  white  substance 
in  each  section,  and  appeared  of  soft  consistence,  and  was  intersected  in 
every  direction  by  dilated  and  engorged  vessels. 

Microscopic  examination  showed  that  the  ganglion  cells  of  the  anterior 
grey  horns  had  almost  completely  disappeared  throughout  the  entire  length 
of  the  spinal  cord  {Fig.  196,  1  to  4).  The  central  column  and  anterior  horns 
were  intersected  with  dilated  blood-vessels,  the  walls  of  the  vessels  were 
thickened,  the  nuclei  of  the  neuroglia  were  greatly  increased  in  number, 
and  the_^ tissue  was  infiltrated  with  leucocytes.  In  some  sections  the  ceUs 
of  the  vesicular  column  of  Clarke  appeared  smaller  and  roimder  than 
normal,  but  on  the  whole  this  column  did  not  seem  to  be  much  affected 
with  disease.  The  posterior  grey  horns  appeared  normal  in  every  respect. 
The  upward  continuation  of  the  central  grey  column  in  the  medulla  oblon- 
gata {Fig.  196,  5)  presented  similar  morbid  appearances  to  those  observed 
in  the  grey  substance  of  the  spinal  cord,  and  the  cells  of  the  accessory 
nuclei,  as  well  as  those  of  the  nucleus  of  the  eleventh  nerve,  had 
disappeared  ;  but  the  fundamental  cells  of  the  hypoglossal  nucleus,  instead. 
of  being  destroyed,  were  hypertrophied.  A  few  hypertrophied  cells  were 
also  observed  in  some  sections  in  the  centres  of  the  internal  and  antero- 
lateral groups  in  the  cord,  especially  in  the  cervical  region,  while  others 
were  represented  by  small  angular  masses  without  processes  ;  but  all  the 
accessory  cells,  and,  indeed,  the  majority  of  the  fundamental  cells  in  the 
cord,  had  disappeared  without  a  trace  of  them  being  left. 

On  holding  a  section  from  the  middle  of  the  dorsal  region  up  to  the 
light,  a  patch,  which  was  more  highly  coloured  by  carmine  than  the 
surrounding  tissue,  could  be  distinctly  observed  in  the  posterior  root-zone, 
where  it  adjoins  the  column  of  GoU.  It  began  near  the  posterior  com- 
missure, and  extended  backwards  towards,  although  it  did  not  reach,  the 
posterior  surface  of  the  cord.  The  deeply-stained  portions  were  symmetri- 
cally placed  on  each  side  of  the  columns  of  GoU,  and  to  the  naked  eye 


926 


SYSTEM  DISEASES   OF  THE 


Fig.  196. 


they  presented  all  the  characters  of  patches 
of  sclerosis  {Fig.  196,  2).  Similar  patches 
were  observed  in  the  cervical  region,  but 
they  were  more  diffused  than  those  in  the 
dorsal  region,  their  areas  were  larger,  and 
they  did  not  stain  so  deeply  with  carmine. 
In  many  sections  the  peripheral  layer  of  the 
cord  was  deeply  stained,  this  being  espe- 
cially marked  in  the  anterior  root-zones  and 
columns  of  Tiirck.  When  the  deeply-stained 
portions  were  examined  microscopically,  the 
connective-tissue  septa  were  found  swollen, 
a  few  of  the  nerve  fibres  had  disappeared, 
but  the  majority  of  these  were  normal.  The 
most  remarkable  morbid  alteration,  how- 
ever, observed  was  the  great  increase  in  the 
number  of  Deiter's  cells. 

A  large  nimaber  of  the  nerve  fibres  of  the 
anterior  roots  had  undergone  atrophy,  and 
some  of  the  bundles  were  replaced  by  con- 
nective tissue.  A  considerable  nmnber  of 
the  fibres,  however,  appeared  normal. 

Portions  of  the  anterior  muscles  of  the 
leg,  and  of  those  of  the  hypothenar  eminence, 
were  subjected  to  microscopical  examina- 
tion by  Dr.  Leech,  who  kindly  examined 
those  muscles  for  me,  and  submitted  the 
following  report : — 

"  On  transverse  section  the  muscular 
fibres  are  seen  to  be  separated  by  an  undue 
amount  of  fibrous  tissue,  while  the  nuclei 
of  the  endomysium  are  greatly  increased  in 
number.  The  fibres  themselves  vary  in 
diameter,  some  of  them  being  considerably 
smaller  than  others,  and  the  nuclei  beneath 
the  sarcolemma  are  increased  in  number. 
Examination  of  longitudinal  sections  shows 


Fig.  19G  (Young).  Transverse  Sections  of  the 
Spinal  and  Medulla  Oblongata  at  different 
levels,  from  a  case  of  chronic  atrophic  spinal 
paralysis,  shoioing  the  disappearance  of  the 
ganglion  cells.  —  1,  Middle  of  the  lumbar 
enlargement  ;  2,  Middle  of  the  dorsal  region  ; 
3,  Middle  of  the  cervical  enlargement ;  4,  Sec- 
tion on  a  level  with  the  origin  of  the  second 
cervical  nerve ;  5,  Section  of  the  medulla 
oblongata  on  a  level  with  the  middle  third  of 
the  olivary  body. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  927 

that  the  muscle  corpuscles  are  increased  in  number,  and  that  the 
structure  of  the  muscular  fibre  is  greatly  altered  in  other  respects. 
Many  of  the  muscular  fibres  are  granular,  their  transverse  striation 
is  indistinct  or  wanting,  and  the  muscle  corpuscles  are  increased  in 
number.  The  most  remarkable  changes  observed,  however,  consisted  in  an 
alteration  of  the  normal  relation  of  the  contractile  and  interstitial  discs. 
The  contractile  discs  seemed  to  be  shortened,  and  swelled  out  laterally. 
In  consequence  of  this  change,  the  interstitial  discs  appeared  as  transverse, 
more  or  less  transparent,  bands  between  the  darker  bars  formed  by  the 
contractile  discs,  and  the  former  being  also  narrower  than  the  latter,  the 
outline  of  the  fibre  has  a  rugose  or  serrated  appearance. 

"  Several  nuclei  are  sometimes  observed  in  the  transparent  bands, 
while  one  or  more  muscle  corpuscles  are  obscurely  seen  in  the  darker 
bars. 

"It  is  doubtful  how  far  the  changes  just  described  are  the  result  of 
disease,  inasmuch  as  similar  appearances  may  sometimes  be  seen,  although 
never  to  the  same  extent,  in  healthy  muscle  withdrawn  dm"ing  life  by  the 
muscle  trocar  ;  and  the  autopsy  in  this  case  being  conducted  a  few  hours 
after  death,  the  muscle  would  have  been  placed  in  preservative  fluid  before 
post-mortem  rigidity  had  taken  place." 

§  411.  Morbid  Anatomy  and  Physiology. — Very  few  post- 
mortems of  this  affection  have  hitherto  been  obtained.  Cases 
have  been  reported  by  Cornil  and  Webber  in  which  the  spinal 
cord  was  examined ;  the  chief  changes  were  found  in  the  grey 
anterior  horns,  and  consisted  of  disappearance  and  atrophy  of 
the  ganglion  cells,  destruction  of  their  processes,  thickening  of 
the  walls  of  the  blood-vessels,  and  exudation  of  white  and  a  few 
red  blood  corpuscles  into  the  perivascular  spaces. 

A  case  of  chronic  atrophic  spinal  paralysis  has  been  described 
by  Aufrecht,^  in  which  a  post-mortem  examination  had  been 
obtained,  and  the  spinal  cord,  nerves,  and  muscles  subjected 
to  careful  microscopic  examination.  The  appearances  observed 
correspond  on  the  whole  pretty  closely  with  those  just  described. 
In  Aufrecht's  case,  however,  the  ganglion  cells  of  the  anterior 
horns  were  by  no  means  changed  to  anything  like  the 
same  extent  they  were  in  the  case  observed  by  me.  From  a 
careful  examination  of  Aufrecht's  description  of  the  morbid 
alterations  in  the  anterior  horns,  it  is  evident  to  me  that  the 

*  Aufrecht  (E.).  "Die  Ergebnisse  eines  Falles  von  subacuter  Spinal-Paralyse, 
insbesondere  fiir  die  Lehre  von  der  Muskel-  und  Nerven-Degeneration."  Deutaches 
Arch.  f.  klin.  Med.,  Bd.  XXII.,  1878,  p.  33. 


928  SYSTEM  DISEASES  OF  THE 

fundamental  cells  were  hypertrophied,  and  that  some  of  the  acces- 
sory cells  were  shrivelled,  while  it  is  probable  that  a  considerable 
number  of  them  had  disappeared. 

§  412,  Diagnosis. — The  chronic  may  be  distinguished  from 
the  acute  form  of  anterior  poliomyelitis  by  the  slow  and  gradual 
manner  in  which  the  former  and  the  sudden  way  in  which  the 
latter  begins.  The  subacute  or  chronic  form  has  for  some  time 
a  progressive  course,  and  extends  more  or  less  gradually  upwards, 
and  the  disease  may  terminate  fatally  or  advance  slowly  towards 
recovery.  The  course  of  this  disease,  therefore,  differs  greatly 
from  that  of  the  acute  form. 

Progressive  muscular  atrophy  may  be  distinguished  from 
chronic  atrophic  spinal  paralysis  by  the  circumstance  that  in  the 
former  the  paralysis  and  atrophy  proceed  side  by  side,  while  in 
the  latter  the  paralysis  precedes  the  atrophy;  again,  in  the 
former  the  atrophy  is  partial,  and  in  the  latter  the  muscle  wastes 
as  a  whole.  In  progressive  muscular  atrophy  the  middle  form  of 
the  reaction  of  degeneration  is  met  with,  and  reflex  action  is 
retained ;  while  in  chronic  atrophic  spinal  paralysis  the  reaction 
of  degeneration  is  well  marked  and  reflex  action  is  abolished ; 
and,  lastly,  progressive  muscular  atrophy  runs  a  slow  and  always 
unfavourable  course,  while  chronic  poliomyelitis  runs  a  com- 
paratively rapid  course  and  frequently  ends  favourably.  It  is 
not  improbable  that  some  cases  which  are  usually  classed  as 
partial  progressive  muscular  atrophy,  but  which  are  not  pro- 
gressive, really  belong  to  the  category  of  chronic  anterior 
poliomyelitis. 

Amyotrophic  lateral  sclerosis  resembles  chronic  poliomyelitis 
in  the  paralysis  and  atrophy  of  the  muscles  of  the  upper  ex- 
tremities, but  in  the  lower  extremities  there  is  paralysis  with 
tension  of  the  muscles,  contractures,  and  increase  of  the  tendon 
reflexes,  normal  or  only  slightly  altered  electrical  reactions,  and 
no  atrophy.  The  diagnosis  between  paralysis  ascendens  acuta 
and  chronic  poliomyelitis  has  already  been  described. 

Chronic  atrophic  spinal  paralysis  may  be  distinguished  from 
transverse  myelitis,  multiple  sclerosis,  tabes  dorsalis,  spastic 
spinal  paralysis,  and  all  other  forms  of  chronic  spinal  disease, 
if  due   attention  be  paid  to  the  state  of  the  sensibility,  the 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  929 

functions  of  the  bladder,  the  nutrition  of  the  skin,  reflex  action, 
and  the  electrical  excitability  of  the  muscles. 

§  413.  Prognosis. — The  prognosis  is  comparatively  favourable. 
Recovery  takes  place  in  the  maority  of  cases,  and  improvement, 
as  a  rule,  goes  much  further  than  in  the  acute  form.  At  the 
same  time  it  must  be  remembered  that  chronic  atrophic  spinal 
paralysis  is  not  like  infantile  paralysis  in  being  free  from  all 
danger  to  life.  The  more  partial  forms  of  the  disease  are  never 
dangerous  to  life,  although  they  may  lead  to  permanent  atrophy 
of  the  muscles  affected. 

§  414.  Treatment. — The  same  principles  are  applicable  in  the 
treatment  of  this  disease  as  for  subacute  and  chronic  myelitis 
generally.  Antiphlogistic  treatment  should  first  be  employed 
and  afterwards  the  use  of  the  galvanic  current  and  a  stimulating 
and  supporting  treatment. 

(4)  Periependymal  Myelitis — Syringomyelia — Hydromyelia. 

§  415.  Definition. — The  symptoms  of  this  affection  are  some- 
what variable,  but  the  form  with  which  we  have  to  deal  at  present 
is  characterised  by  the  presence  of  paralysis,  which  may  begin  in 
the  lower  or  upper  extremities  and  pursue  an  ascending  or  a 
descending  course ;  the  paralysed  muscles  undergo  atrophy  and 
their  faradic  contractility  is  diminished  at  an  early  period  of  the 
disease. 

§  416.  History. — Althougli  cases  in  wliich  a  central  cavity  had  been 
found  in  tlie  spinal  cord  had  been  observed  by  Morgagni  and  others,  yet 
Nonat^  gave  in  1838  the  first  accurate  description  of  the  condition.  Since 
that  time  cases  have  been  described  by  Jolyet,^  Lancereaux,^  and  others, 
but  the  case  of  progressive  atrophy  of  the  muscles  of  the  hand  reported  by 
Gull,*  in  which  a  central  cavity  was  found  after  death  in  the  cervical  region 

*  Nonat.  "  Eecherches  sur  le  d^veloppement  accidentel  d'un  canal  rempli  de 
serosit^  dans  le  centre  de  la  moelle."    Arch,  gen^r.  de  m^d.,  1838,  p.  287. 

*  Jolyet.  "Sur  un  cas  d'anomalie  du  canal  central  de  la  moelle  ^piniere." 
Gaz.  m^d.  de  Paris,  1867. 

^  Lancereaux.  "  Un  cas  d'hypertrophie  de  I'dpendyme  spinal  avec  obliteration 
du  canal  central  de  la  moelle."  Mem,  de  la  Soc.  de  Biol.,  3rd  Series,  Tome  III., 
1862. 

*  Gull.  "  Case  of  progressive  atrophy  of  the  hands :  enlargement  of  the  ventricle 
of  the  cord  in  the  cervical  region,  with  atrophy  of  the  grey  matter."  Guy's  Hospital 
Reports,  3rd  Series,  Vol.  VIII.,  1862,  p.  244. 

VOL.  L  HHH 


930  SYSTEM  DISEASES  OF  THE 

of  the  spinal  cord,  was  the  first  to  bring  this  condition  prominently  under 
the  notice  of  the  profession.  The  pathology  of  the  disease  was  for  the  first 
time  placed  upon  a  satisfactory  basis  by  Hallopeau,^  while  WestphaP  and 
Simon'  have  subsequently  made  important  contributions  to  the  subject. 

§  417.  Etiology. — The  causes  of  this  disease  are  the  same  as 
those  of  other  forms  of  myelitis. 

§  418.  Symptoms. — This  affection  usually  begins  somewhat 
abruptly  by  paralysis  of  some  muscular  groups.  The  patient 
suddenly  finds  that  he  is  not  able  to  move  the  fingers,  hands,  or 
more  rarely  an  entire  limb.  An  electrical  examination  of  the 
paralysed  muscles  shows  that  their  faradic  contractility  is  lost  at  an 
early  period  of  the  disease ;  the  muscles  also  become  atrophied,  and 
the  affected  extremities  assume  deformed  positions.  The  affected 
muscles  may  be  the  subjects  of  fibrillary  contractions,  and  in 
some  cases  involuntary  movements  of  the  limb  or  trunk  have 
been  observed.  The  patient  may  complain  of  vague  pains  along 
the  vertebral  column,  but  other  sensory  disturbances  are  often 
absent,  and  the  sphincters  also  remain  unaffected.  When  the 
cavity  is  situated  in  the  posterior  columns  of  the  cord,  the 
patient  may  complain  of  numbness  and  tingling,  and  there  may 
be  an  extensively  diffused  ansesthesia,  as  in  the  case  recorded 
by  Schiippel,*  which  was  frequently  exhibited  during  life  in 
Niemeyer's  clinic,  but  even  in  such  cases  an  ataxic  walk  has 
never  been  observed. 

§  419.  Course,  Duration,  and  Terminations. — The  course 
of  the  affection  is  slow,  and  it  may  be  temporarily  arrested  for  a 
long  time,  or  may  even  regress,  and  then  the  muscles  implicated 
gradually  regain  motor  power  and  recover  their  volume  so  that 
complete  or  almost  complete  recovery  may  take  place.     After  a 

*  Hallopeau.  "  Note  sur  un  cas  de  sclerose  diffuse  de  la  moelle  avec  lacune  au 
centre  de  cet  organe,  alteration  de  la  substance  grise,  atropbie  musculaire."  Gaz. 
m^d.  de  Paris,  1870,  p.  183;  et  Arch,  gener.  de  m^d.,  1871,  pp.  435,  565;  et  1872 
pp.  60,  191. 

*  Westphal  (C).  "  Ueber  ein  Fall  von  Hohlen-  und  Geschwulsthildung  im 
Riickenmarke  mit  Erkrankung  des  verlangerten  Marks  und  einzelner  Hirnnerven." 
Arch,  fiir  Psychiat.,  Bd.  V.,  1874,  p.  90. 

^  Simon  (Th.).  "Beitrage  zur  Pathologie  und  pathologischen  Anatomic  des 
Central-Nervensystems."    Arch,  fiir  Psychiat.,  Bd.  V.,  1874,  p.  108. 

*  Schiippel.   "Ueber  Hydromyelus."   Arch,  der  Heilkunde,  Bd.  VI.,  1865,  p.  289. 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  931 

time,  however,  a  relapse  occurs ;  some  of  the  muscles  which  were 
formerly  implicated  become  suddenly  paralysed,  or  the  paralysis 
may  begin  in  the  extremities  which  were  previously  spared,  and 
thus  the  afifection  progresses  by  successive  amendments  and 
relapses  until  at  last  it  becomes  permanently  established.  The 
muscles  of  the  lower  extremities  most  frequently  affected  are 
the  flexors  of  the  foot  on  the  leg,  and  of  the  thigh  on  the 
pelvis,  and  of  the  upper  extremities  are  the  extensors  of  the 
fingers  and  of  the  hand,  then  the  small  muscles  of  the  hand, 
and  Isistly  the  flexors  of  the  forearm  and  the  muscles  of  the  arm 
and  shoulder.  The  affection  pursues  an  ascending  course  when 
the  lower  extremities  are  the  first  to  be  affected,  and  it  generally 
pursues  an  ascending  and  a  descending  course  when  the  upper 
extremities  are  attacked  first,  and  bulbar  paralysis  is  ultimately 
liable  to  supervene  and  to  cause  death.  In  some  cases  there  is  a 
rapid  upward  extension  of  the  paralytic  symptoms,  and  then  the 
affection  may  be  mistaken  for  an  acute  ascending  paralysis.^ 

§  420.  Morbid  ATwiom/y  and  Physiology. — In  periependymal 
myelitis  the  epitheloid  cells  which  form  the  lining  of  the  central 
canal,  and  the  cells  of  the  neuroglia  which  surround  it,  undergo 
proliferation,  so  that  the  whole  of  the  central  grey  column 
becomes  altered  in  structure.  In  some  cases  the  morbid  tissue 
appears  to  consist  chiefly  of  epitheloid  cells,  which  are  irregu- 
larly polyhedral  in  form,  and  which  may  be  pressed  closely 
against  one  another,  or  separated  by  a  variable  quantity  of 
amorphous  material.  A  case  is  described  by  Vulpian^  in  which 
the  whole  of  the  central  parts  of  the  cord  were  occupied  by 
these  cells,  forming  a  dense  mass,  which  obliterated  the  central 
canal  and  extended  laterally  and  backwards  towards  the  posterior 
roots.  In  most  cases,  however,  the  morbid  process  begins  in  the 
neuroglia  surrounding  the  central  canal,  and  instead  of  the 
spongy  tissue  which  is  met  with  in  the  normal  cord  the  central 
grey  column  becomes  converted  into  a  solid  mass  of  fibroid 
tissue   which    grows   from   within    outwards,  and    invades  the 

*  See  Leyden.  Traits  clinique  des  maladies  de  la  moelle  ^piniere.  Paris,  1879. 
p.  703. 

^  See  Hallopeau.  Nouveau  Dictionnaire  de  Medecine  et  chirurgie  pratiques. 
Art.  "MoeUe  Epiniere."    Tome  XXII.,  1876,  p.  652. 


932  SYSTEM  DISEASES   OF  THE 

remaining  parts  of  the  grey  matter.      This  central  core  may 
present  a  solid  mass  throughout  the  whole  extent  of  the  cord, 
but  in  most  cases  a  portion  of  the  interior  undergoes  softening, 
and  a  cavity  is  formed  which  is  filled  with  serous  fluid.     The 
cavity  varies  much  in  its  dimensions ;  it  extends  sometimes  the 
whole  length  of  the  cord,  while  at  other  times  it  is  only  a  few 
lines  in  length,  and  on  transverse  section  it  is  at  times  large 
enough  to  admit  the  tip  of  the  finger,  while  at  other  times  it  is 
only  large  enough  to  be  visible  to  the  naked  eye.     The  cavity 
sometimes  occupies  the  position  of  the  central  canal  of  the  cord ; 
but  Simon  states  that  it  is  most  usually  situated  in  that  part  of 
the  posterior  columns  which  adjoins  the  posterior  commissure, 
and  the  central  canal  can  generally  be  found  lying  in  front, 
or  occasionally   behind,    or   still   more    rarely    communicating 
with  it.     The  walls  of  the  excavation  are  smooth  and  generally 
naked,  but  in  some  cases  it  was  found  to  have  been  lined  by  epi- 
thelium, and  in  these  it  is  likely  that  the  cavity  is  caused  by  a 
dilatation  of  the  central  canal.    The  cavity  is  always  surrounded 
by  a  ring  of  fibroid  tissue,  which  grows  from  within  outwards  and 
invades  the  grey  substance  of  the  cord,  and  may  even  extend  to  the 
white  substance,  the  lateral  columns  being  particularly  liable  to  be 
invaded.     It  must  be  remembered  that  the  sclerosed  tissue  may 
extend  the  whole  length  of  the  cord,  while  the  cavity  only  occu- 
pies a  very  small  part  of  its  vertical  extent,  as  in  a  case  reported 
by  Lancereaux,  in  which  the  whole  of  the  central  grey  column 
was  converted  into  a  dense  mass  of  sclerosed  tissue,  except  the 
cervical  region,  where  a  small  cavity  was  observed  in  its  sub- 
stance.    In  other  cases  the  cavity  itself  forms  the  predominating 
feature  of  the  morbid  change.     In  a  case  recorded  by  Hallopeau, 
the  cavity  began  in  the  cervical  region,  and  extended  downwards 
to  the  lower  end  of  the  dorsal  region,  and  in  some  cases  the 
whole  of  the  interior  of  the  cord  may  be  so  distended  with  fluid 
that  a  considerable  portion  of  it  is  converted  into  a  fluctuating 
sack.     The  excavations  have  been  found  most  frequently  in  the 
upper  dorsal  and  lower  cervical  regions.     In  the  annexed  woodcut 
{Fig.   197),  borrowed    from   Leyden's^  work,  a  section  of  the 
cervical  enlargement  of  the  spinal  cord,  from  a  case  of  syriDgo- 

'  Leyden.     Klinik  der  Euckenmarkskrankheiten.     Bd.  II.,   1877,  453  et  seq. 
(Taf.  IV.,  Fig.  3). 


SPINAL   CORD   AND  MEDULLA  OBLONGATA, 


983 


myelia,  is  represented  ;  the  central  grey  column  in  the  case  from 
which  the  section  was  taken  was  changed  into  a  substance  of 
gelatinous  consistence,  which  at  certain  points  in  its  longitudinal 
extent  became  softened  so  as  to  have  formed  cavities. 

Fig.  197. 


Fig.  197  (from  Leyden).     Transverse  Section  of  the  Spinal  Cord  from  the  Middle  of 
the  Cervical  Enlargement,  from  a  case  of  Syringomyelia,  showing  a  cavity  behind  ' 
the  posterior  commissure,  and  destruction  of  a  large  portion  of  the  ganglion  cells 
of  the  anterior  grey  horns. 

In  a  case  observed  by  Sir  William  Gull/  a  considerable  dilata- 
tion of  the  spinal  canal  {Fig.  198)  was  found  in  the  cervical  region, 
between  the  fifth  cervical  vertebra  and  the  origin  of  the  third  and 
fourth  dorsal  nerves.  The  cavity  was  full  of  serous  fluid,  and, 
with  the  exception  of  a  thin  layer  which  surrounded  it,  and  could 
be  stripped  off  like  a  membrane,  the  grey  substance  had  dis- 
appeared,  while   the   white  substance  and  the  anterior  nerve 


Fig.  198. 


Fig.  198  (after  Gull).  Transverse  Section  of  the  Cervical  Enlargement  of  the  Spinal 
Cord,  showing  a  central  cavity,  which  has  destroyed  considerable  portions  of  the 
anterior  grey  horns. 

'  GulL  _"  Case  of  progressive  atrophy  of  the  muscles  of  the  hands  :  enlargement 
of  the  ventricle  of  the  cord  in  the  cervical  region,  with  atrophy  of  the  grey  matter." 
Guy's  Hospital  Reports,  3rd  Series,  Vol.  VIII.,  1862,  p.  244. 


934  SYSTEM  DISEASES   OF  THE 

roots  seemed  normal.  In  a  case  observed  by  Scliiippel,^  the 
hydro myelia  extended  down  to  the  tenth  dorsal  vertebra.  Grimm^ 
also  found  considerable  enlargement  of  the  central  cavity  at  the 
expense  of  the  grey  substance,  the  latter  being  flattened  by 
pressure  to  a  ring-shaped  plate,  but  in  this  case  the  cord  in  the 
lower  cervical  and  upper  dorsal  regions  presented  a  fusiform 
swelling,  caused  by  the  growth  of  a  medullary  sarcoma.  The 
cavity  of  the  cord  in  the  case  reported  by  Westphal  was  caused 
by  the  softening  of  a  gliosarcomatous  tumour.^  In  the  latter 
series  of  cases,  the  destruction  of  the  ganglion  cells  appears  to 
have  been  caused  indirectly  by  the  pressure  of  the  fluid  which 
had  distended  the  central  canal. 

Diagnosis  and  Prognosis. — It  is  probable  that  this  affection 
cannot  with  certainty  be  recognised  during  life.  It  is  distin- 
guished from  progressive  muscular  atrophy  chiefly  by  the  early 
establishment  of  the  reaction  of  degeneration  in  the  muscles. 
It  is,  however,  impossible  to  distinguish  it  from  the  subacute 
ascending  general  paralysis  of  Duchenne,  but  it  may  be  sur- 
mised that  a  cavity  is  present  in  the  cord  if  the  case  progress  by 
successive  amendments  and  relapses.  I  have  a  strong  suspicion 
that  the  followiEg  case  is  an  example  of  the  disease. 

For  the  notes  of  the  case  I  am  indebted  to  Mr.  J.  Hayes,  at 
the  time  one  of  the  House  Physicians  to  the  Infirmary. 

Case  V. — Ann  E ,  aged  thirty-tkree  years,  and  unmarried,  entered 

the  Manchester  Eoyal  Infirmary  on  May  25th,  1882,  under  the  care  of  Dr. 
Eoss.  The  patient's  occupation  is  "  cotton-balhng,"  -which  necessitates  her 
holding  on  the  pahn  of  either  hand  a  ball  of  cotton,  which,  although  not 
heavy,  is  often  of  considerable  size,  while  she  winds  upon  it  the  cotton  as  it 
is  prepared  for  being  drawn  out  into  thread.  She  always  enjoyed  good  health 
and  never  had  any  serious  ailment  until  between  seven  and  eight  years 
ago.  At  that  time  she  felt  her  hands  very  feeble  and  awkward  whilst  at 
work,  and  she  observed  that  when  her  forearms  were  held  out  horizontally 
with  the  palms  downwards  the  little  and  ring  fingers  hung  powerless, 
and  she  was  imable  by  any  voluntary  effort  to  stretch  them  out.  The 
feebleness  of  the  hands  now  increased  so  rapidly  that  she  was  obhged  to 
give  over  her  work  for  a  time.  During  this  time  she  had  a  sHght  pain 
between  the  shoulders,  but  there  was  no  other  disturbance  of  sensation. 

1  Schiippel.  "UeberHydromyelus."  Arch,  der  Heilkunde,  Bd.  VI. ,  1865,  p.  289. 
^  Grimm  (J.).     "  Ein  Fall  von  progressive  Muskelatrophie."    Virchow's  Arch., 
Bd.  XLVIIL,  1869,  p.  445. 

^  See  Schultze.     Virchow's  Archiv.     Bd.  LXXXVII.,  1882,  p.  510. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  935 

With  rest  she  improved  rapidly  and  was  able  to  resume  her  occupation  in 
three  weeks,  and  she  continued  to  work  for  three  years  afterwards  without 
feeling  any  weakness  of  her  hands.  Five  years  ago  last  November  she  felt 
very  iU  and  had  a  fit,  which  appears  to  have  been  hysterical ;  she  could  not 
use  her  hands  for  some  months,  jiaralysis  of  both  the  hands  appearing  to 
develop  this  time  very  suddenly.  The  patient  gradually  regained  motor 
power,  and  she  states  that  at  the  end  of  six  or  seven  months  every  trace  of 
the  paralysis  had  disappeared,  but  she  did  not  return  to  her  work  for  a 
considerable  time  afterwards.  Diu-ing  the  last  four  years  paralysis  of  the 
hands  has  recurred  several  times,  so  that  her  history  during  that  time  has 
been  that  whenever  she  worked  for  some  time  at  her  occupation  of  cotton- 
baUing  the  hands  became  more  or  less  suddenly  paralysed,  and  then  on 
resting  from  three  to  foiu-  months  gradual  recovery  took  place,  to  be 
followed  by  a  relapse  on  resuming  her  work.  For  the  last  two  years  she 
has  not  worked  more  than  a  few  weeks  at  a  time  when  the  paralysis 
reappeared,  and  lately  a  few  days  at  her  work  sufficed  to  induce  an  attack. 
The  patient  believes  the  present  to  be  her  seventh  attack  of  paralysis  of 
the  hands.  Her  sister,  whose  occupation  is  also  "  cotton-balling,"  was  in 
the  Infirmary  a  few  weeks  ago,  under  the  care  of  Dr.  Eoberts,  with  paralysis 
of  both  hands,  which  corresponded  in  its  distribution  and  in  the  electrical 
reactions  of  the  paralysed  muscles,  and  in  every  other  respect  to  the  condi- 
tion of  the  patient.  This  was  her  sister's  first  attack,  and  it  may  be  stated 
at  present  that  she  has  since  become  an  out-patient  under  the  care  of  Dr. 
Dreschfeld  and  made  a  perfect  recovery. 

Present  Condition. — The  patient  is  weU  nourished,  and  of  a  healthy 
appearance,  except  that  her  eyelids  are  a  httle  puffy,  and  the  eye  is 
watery,  but  there  is  no  albumen  in  the  urine,  all  her  internal  organs  are 
healthy,  and  there  is  no  blue  line  on  the  gums.  When  the  forearms  are 
held  out  horizontally,  with  the  palms  directed  downwards,  both  hands  drop 
at  the  wrists  as  in  lead  paralysis.  She  is  unable  to  extend  the  thumb  at 
the  wrist,  the  fingers  at  the  metacarpo-phalangeal  joints,  or  the  thumb  at 
the  metacarpo-phalangeal,  or  phalangeal  joints.  When  the  first  phalangeal 
bones  are  fixed  on  a  line  with  the  metacarpal  bones  and  forearm,  she 
cannot  extend  the  middle  and  little  fingers  at  the  phalangeal  joints  on  the 
right  side,  but  she  can  extend  all  on  the  left  side  with  the  exception  of  the 
middle  finger.  When  the  hand  is  placed  with  the  palm  fiat  on  a  table  she 
is  unable  to  separate  the  fingers  from  the  middle  finger  with  any  degree  of 
force.  She  can  adduct  the  thumb  and  flex  it  feebly  at  both  joints,  but  she 
cannot  extend  it  at  either  joint,  abduct  it,  or  produce  opposition.  The 
grasp  is  weak,  and  flexion  at  the  wrist  is  feeble,  but  the  long  flexors  of  the 
fingers  and  the  flexors  at  the  wrist  are  not  completely  paralysed.  The 
thenar  and  hypothenar  eminences  are  flattened,  and  the  bones  can  be  felt 
through  them  as  if  they  were  immediately  underlying  the  skin.  Both 
hands  have  a  characteristic  claw  appearance.  The  pronators,  supinators, 
and  all  the  muscles  of  the  upper  arm  and  shoulder  appear  to  be  free  from 
disease.     The  supinator  longus  muscle  on  the  right  side  contracts  to  a 


936  SYSTEM  DISEASES  OF  THE 

feeble  faradic  current.  The  extensors  of  the  wrist,  thumb,  index,  and  little 
fingers,  and  the  common  extensor,  the  opponens  and  abductor  pollicis  do 
not  contract  to  the  strongest  faradic  current.  The  flexors  of  the  wrist,  the 
superficial  and  deep  flexors  of  the  fingers,  the  muscles  of  the  hypothenar 
eminence,  the  flexor  brevis  and  adductor  pollicis  contract  to  a  medium 
current.  The  corresponding  muscles  of  the  left  arm  give  reactions  similar 
to  those  of  the  right  side.  With  the  galvanic  current  the  supinator  longus 
of  the  right  side  contracts  with  35  cells  Leclanch§  on  cathodal  closure  and 
40  cells  on  anodal  closure.  The  extensor  communis  digitorum  contracts 
with  30  cells  on  cathodal  closure  and  20  on  anodal  closure  ;  the  extensor 
carpi  ulnaris  and  extensor  minimi  digiti  with  30  cells  on  cathodal  closure 
and  15  on  anodal  closure ;  the  extensor  carpi  radialis  with  25  cells  on 
cathodal  closm-e  and  25  on  anodal  closure ;  the  long  flexor  of  the  fingers 
with  25  cells  on  cathodal  closure  and  35  on  anodal  closure  ;  the  muscles  of 
the  hypothenar  eminence  with  25  cells  on  cathodal  closure  and  25  on 
anodal  closure  ;  the  flexor  brevis  pollicis  with  35  cells  on  cathodal  closure 
and  35  on  anodal  closure  ;  and  the  opponens  pollicis  with  25  cells  on 
cathodal  closure  and  25  on  anodal  closure.  Similar  reactions  were 
obtained  from  the  muscles  of  the  left  forearm  and  hand.  The  patient 
stated  that  the  tips  of  her  fingers  felt  somewhat  numb,  and  occasionally 
as  if  they  were  bm-ning,  but  there  was  no  diminution  of  sensation 
to  objective  examination.  She  also  complained  of  tingling  pains  in  her 
feet,  but  there  was  no  paralysis  of  the  muscles  of  the  lower  extremi- 
ties, and  all  of  them  gave  normal  electrical  reactions.  The  patient 
was  discharged  on  July  5th,  at  her  own  request,  and  became  an  out-patient 
February  1st,  1883.  The  patient  has  continued  to  attend  regularly  as  an 
out-patient,  and  some  slight  degree  of  improvement  has  taken  place  in  the 
condition  of  her  hands.  She  can  now  extend  both  hands  at  the  wrist,  and 
the  fingers  and  thumb  at  the  metacarpo-phalangeal  joints,  although  these 
movements  are  feebly  performed,  and  her  grasp  is  still  very  weak.  Ever 
since  her  stay  in  the  Infirmary  she  has  complained  more  or  less  of  pains 
in  the  feet,  and  lately  they  have  become  very  numb.  She  has  also  sufiered 
for  some  time  from  constrictive  pain  aroimd  the  body  on  a  level  with  the 
false  ribs.  Her  legs  drag,  and,  as  she  expresses  it,  "she  has  lost  all  spring." 
For  some  time  I  have  observed  that  the  anterior  group  of  muscles  of  both 
legs  are  feeble,  but  have  not  had  an  opportunity  of  examining  the  condition 
of  the  lower  extremities  carefully  until  to-day.  The  muscles  above  the 
knee  appear  to  be  nonnal  on  both  sides.  On  the  right  side  below  the  knee 
the  anterior  muscles  of  the  leg  and  the  small  muscles  of  the  foot  are 
completely  paralysed,  while  the  muscles  of  the  calf  only  contract  very 
feebly  by  a  voluntary  effort.  On  the  left  side  a  similar  condition  obtains, 
but  to  a  less  degree.  All  the  muscles  contract  slightly  on  voluntary  effort ; 
but  the  anterior  group  and  the  small  muscles  of  the  foot  only  act  very 
feebly,  and  the  muscles  of  the  calf  are  also  weak.  No  reaction  is  obtained 
in  the  muscles  below  the  knee  with  a  strong  faradic  current ;  feeble 
reactions  are  obtained  on  the  left  side  when  a  very  strong  current  is  used. 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  937 

The  muscles  on  the  right  side  react  to  a  galvanic  current  with  30  cells 
Leclanche  on  cathodal  closure  and  25  on  anodal  closure ;  on  the  left  with 
35  cells  on  cathodal  closure  and  35  on  anodal  closure.  There  is  decided 
diminution  of  the  cutaneous  sensibility  over  both  legs  and  feet.  Pricking 
with  a  pin  and  j)inching  does  not  cause  the  normal  degree  of  pain  ;  two 
points  have  to  be  removed  15  cm.  before  they  are  felt  as  separate  on  the 
outside  of  each  leg,  and  the  patient  cannot  localise  touch  well. 

§  421.  Treatment. — The  treatment  is  the  same  as  for  the 
subacute  ascending  general  paralysis  of  Duchenne. 

(5)  Progressive  Muscular  Atrophy. 

§  422.  Definition. — Progressive  muscular  atrophy  is,  as  its 
name  implies,  a  progressive  wasting  of  the  voluntary  muscles, 
which  pursues  a  chronic  course,  and  attacks  successively  individual 
muscles  and  groups  of  muscles. 

§  423.  History. — Hippocrates  made  a  distinction  between  paralysis 
with  and  without  wasting  of  the  limbs,  and  observed  that  the  former  was 
inciirable.  Cases  of  muscular  wasting,  but  without  paralysis,  were  pub- 
lished in  the  first  half  of  this  century  by  Cooke,^  Abercrombie,^  Darwal,^ 
Bell,*  Parry,^  Graves,^  and  Dubois,''  but  the  affection  was  not  recognised 
as  a  distinct  disease.  In  1850  Duchenne,^  Aran,^  and  Cruveilhier,^"  indepen- 
dently of  each  other,  gave  more  accurate  descriptions  of  the  affection,  and 
recognised  its  claims  to  be  regarded  as  a  distinct  type  of  disease.  Dr. 
Wilham  Eoberts^^  in  1858  collected  all  the  information  existing  on  the  sub- 
ject up  to  that  time  in  an  essay  entitled  "On  Wasting  Palsy;"  and  since 

'  Cooke.  On  Palsy.  Lond. ,  1822.  p.  31.  Quoted  by  Roberts.  An  essay  on 
wasting  palsy,  1858,  p.  2. 

"  Abercrombie  (J.).  On  diseases  of  the  brain  and  spinal  cord.  Edin.,  1878.  p.  419. 

8  Darwal  (J.I.  "Cases  of  a  peculiar  species  of  paralysis."  London  Medical 
Gazette,  Vol.  VIL,  1831,  p.  201. 

"Bell,  The  nervous  system  of  the  human  body.  Lond.,  1830.  Appendix, 
p.  cbd. 

*  Parry  (C.  H.).     Collected  works.    Lond.,  1825.    p.  523. 

^  Graves.  Clinical  Lectures  on  the  practice  of  medicine.  Edited  by  Neligan, 
1864,  p.  384  et  seq. 

''  Dubois.  Gaz.  m^d.  de  Paris,  1841.  Abstr,  Schmidt's  Jahrb.,  Bd.  LXX., 
p.  175. 

«  Duchenne.    Acad,  de  M^d.,  May  2l8t,  1849  ;  and  Union  M^d.,  1852. 

•  Aran.  "  Eecherches  sur  une  maladie  non  encore  d^crite  du  systeme  musculaire 
(atrophic  musculaire  progressive)."  Arch.  g^n.  de  m^d.,  Tome  XXIV.,  Sept.  10th, 
1850,  pp.  5  et  172. 

'"  Cruveilhier.  Arch.  g^n.  de  m^d.,  Mai,  1853,  p.  561;  et  Gaz.  m^d.  de  Paris, 
1853,  Nr.  16. 

*' Eoberts  (W.).    An  essay  on  wasting  palsy.    Lond.,  1858. 


938  SYSTEM  DISEASES   OF  THE 

that  time  tlie  pathology  of  the  disease  has  been  investigated  by  Anstie,^ 
Gull,2  Lockhart  Clarke,^  Luys,*  Charcot/  Hayem,^  Leyden,''  Friedreich,^ 
"Wilks,^  Eulenburg,^"  Hallopeau,"  and  many  others. 

§  424.  Etiology. — Hereditary  predisposition  is  a  powerful 
factor  in  the  production  of  progressive  muscular  atrophy.  Dr. 
Roberts  collected  the  histories  of  ten  families  in  which  a  ten- 
dency to  the  disease  prevailed;  but  the  cases  described  by  Dr. 
Meryon,  which  are  included  in  this  list,  were  probably  in- 
stances of  the  advanced  stage  of  pseudo-hypertrophic  paralysis. 
After  Dr.  Meryon's^^  cases  are  eliminated,  it  may  be  stated 
that  out  of  the  eight  families  referred  to  by  Dr.  Roberts,^^ 
twenty-three  individuals  were  affected,  and  of  these  four  only 
were  females. 

In  a  case  described  by  Hemptenmacher,"  the  disease  could 
be  traced  amongst  the  branches  of  three  families,  who  had 
repeatedly  intermarried,  and  who  had  sprung  from  one  parentage 
a  hundred  and  fifty  years  ago.  In  this  instance  males  only  were 
attacked,  but  the  disease  was  frequently  transmitted  through 
the  female.  Trousseau  mentions  a  family  in  which  the  great- 
grandfather, grandfather,  father,  and  son  suffered  from  the 
disease;  the  course  of  the  disease  was  remarkably  uniform  in 
all  the  generations.     Eulenburg  mentions  the  case  of  a  family 

'  Anstie  (F.  E.)-  "Muscular  atrophy  following  acute  rheumatism."  Medical 
Times  and  Gazette,  VoL  I.,  1861,  p.  115. 

""  GulL     Guy's  Hospital  Reports.    3rd  Series,  Vol.  VIII.,  1862,  p.  244. 

«  Clarke  (L.).  Beale's  Archiv.  of  Medicine,  Vol.  III.,  1861,  p.  1 ;  Vol.  IV., 
1863,  p.  26  ;  and  British  and  Foreign  Medico-Chirurgical  Review,  July,  1862,  p.  215 ; 
and  Medico-Chir.  Transactions,  Vol.  XLIX.,  1866,  p.  171;  Vol.  L.,  1867,  p.  489; 
and  Vol.  LI.,  1868,  p.  249. 

*  Luys.     Gaz.  med.  de  Paris.     1860.     Nr.  22. 

*  Charcot  and  Joffroy.  Arch,  de  Physiol.,  Tome  II.,  1869,  p.  334  ;  and  Charcot. 
Le9ons  sur  les  maladies  du  systeme  nerveux,  Tome  II.,  2nd  Edit.,  1877,  p.  192. 

^  Hayem.    Arch,  de  Physiologic.     Tome  II.,  1869,  p.  263. 
■'  Leyden.     Arch.  f.  Psychiat.     Bd.  VI.,  1876,  p.  271. 
°  Friedreich.    Ueber  progressive  muskelatrophie.     BerL,  1874. 
'' Wilks.     "Progressive  muscular  atrophy."    The  Medical  Times  and  Gazette, 
Vol.  II.,  1868,  p.  633;  and  Guy's  Hosp.  Reports,  3rd  Series,  Vol.  XV.,  1870,  p.  1. 
'"Eulenburg  (A.).     Virchow's  Archiv.,  Bd.  XLIX.,  1870,  p.  446;  Bd.  LIIL, 
1871,  p.  361.    And,  Eulenburg  and  Guttmann.    Arch.  f.  Psychiat.,  Bd.  L,  1868. 

I'Hallopeau.  "Etude  sur  les  my^lites  chroniques  diffuses."  Arch,  g^ner.  de 
m^d.,  Sept.,  1871,  p.  277. 

'*  Meryon.    Medico-Chirurgical  Transactions.    2nd  Series,  Vol.  VII.,  1852,  p.  81. 
1^  Roberts  (W.).    Art.  on  "Wasting  palsy."    Reynolds'  System  of  Medicine, 
Vol.  II.,  1868,  p.  166. 

*  *  Hemptenmacher.  De  aetiologia  atrophias  muscularis  progressivse.  Dissert. 
Berol.,  1862. 


SPINAL  CORD   AND  MEDULLA  OBLONGATA.  939 

where,  out  of  seven  children,  two  brothers  and  two  sisters  were 
attacked,  while  the  remaining  three  brothers  escaped,  and  still 
more  remarkable  examples  of  heredity  are  described  by  Fried- 
reich,^ Hammond,^  and  Naunyn.^ 

The  male  sex  shows  a  much  greater  tendency  to  the  disease 
than  the  female  sex.  Out  of  176  cases  collected  by  Friedreich  only 
33  were  females.  The  disproportion  between  the  sexes  probably 
depends  on  men  being  much  more  exposed  than  women  to  the 
excitincr  causes  of  the  disease.  Dr.  Roberts  asserts  that  women 
of  the  working  classes,  such  as  washerwomen,  domestic  servants, 
and  sempstresses,  are  not  much  less  liable  to  the  disease  than 
men  employed  in  kindred  occupations,  while  on  the  other  hand 
females  belonging  to  the  middle  and  upper  classes  enjoy  a 
remarkable  immunity  from  the  disease.  It  is  difficult  to 
explain  the  cases  which  arise  in  childhood,  and  in  which  the 
male  members  of  the  family  alone  are  attacked.  Mr.  Darwin, 
however,  has  shown  that  many  variations  which  first  appear  in 
one  sex  are  transmitted  to  that  sex  only.  If  this  fact  does  not 
afford  an  explanation,  it  at  least  merges  the  special  into  a 
general  difficulty.  With  regard  to  the  influence  of  age,  the 
disease  is  found  amongst  young  adults  and  middle-aged  in- 
dividuals, and  where  there  is  a  marked  hereditary  tendency 
to  the  affection,  children  are  not  unfrequently  attacked.  The 
development  of  the  disease  in  advanced  life  is  exceptional. 

Progressive  muscular  atrophy  is  often  developed  during  con- 
valescence from  acute  diseases,  such  as  typhus  fever,*  measles,^ 
acute  rheumatism,^  and  cholera  with  protracted  typhoid  stage; 
and  Charcot  and  Jeffrey''  have  observed  it  to  occur  immediately 
after  childbed.  Venereal  excess,  especially  onanism,^  has  been 
supposed  by  many  authors  to  be  a  fruitful  source  of  the  affec- 


1  Friedreich.    Ueber  progressive  muskelatrophie.    BerL ,  1873.    p.  46. 

*  Hammond.     Diseases  of  the  nervous  system.     7th  Edit.,  1881,  p.  547. 

3  Naunyn  and  Eichhorst.    Berl.  klin.  Wochenschrift,  1873,  Nos.  42  and  43. 

*  Gerhardt  und  Vogt.  "  Ueber  progressive  muskelatrophie."  Berl.  klin. 
Wochenschrift,  Bd.  VIII.,  1871,  p.  265. 

*  Nesemann.  "  Die  Heilung  eines  bis  zur  vollstandigen  Lahmung  aller  Extremi- 
taten  vorgescbrittenen  Ealles  von  progressiver  muskelatrophie  vermittelst  des  cou- 
stanten  galvanischen  Stromes."    Berl.  klin.  Wochenschrift.,  Bd.  V.,  1868,  p.  380. 

«  Anstie  (F.  E.).     Medical  Times  and  Gazette.     February,  1861. 
^  Charcot  and  Joffroy.    Arch,  de  Physiol.    1869.     p.  356. 

*  Aran.    Arch,  g^n^r.  de  med.    Sept.,  1850.    p.  27. 


Q40  SYSTEM  DISEASES  OF  THE 

tion,  although  the  evidence  upon  which  the  opinion  is  founded 
is  doubtful.  Chronic  lead  poisoning  is  not  unfrequently 
attended  by  a  diffused  wasting  of  the  muscles,  closely  resem- 
bling progressive  muscular  atrophy,  and  a  similar  wasting  also 
occurs  in  constitutional  syphilis. 

Of  the  exciting  causes  of  the  disease  unusual  muscular  exertion 
deserves  the  chief  place.  That  excessive  muscular  efforts  tend 
to  develop  the  disease  is  shown  by  the  fact  that  the  atrophy 
attacks  by  preference  the  groups  of  muscles  which  must  be 
maintained  in  long-continued  contraction  with  persons  following 
certain  avocations,  such  as  blacksmiths,  tailors,  masons,  and 
shoemakers.  Betz^  observed  atrophy  of  the  muscles  of  the  right 
side  in  smiths  and  saddlers,  who  had  to  do  heavy  work  with 
their  right  hands;  in  the  case  of  a  stonemason  which  came 
under  ray  notice  the  atrophy  began  in  the  muscles  of  the  right 
hand,  and  a  striker  in  ironworks  was  recently  under  my  care  who 
had  diffused  atrophy  of  the  rhomboid  muscles  and  of  the  lower 
half  of  the  trapezius  on  both  sides.  In  persons  who  have  to 
perform  manual  labour  the  disease  generally  begins  in  the 
muscles  of  the  shoulders,  arms,  and  hands  ;  and  the  right  side  is 
generally  the  first  to  be  affected.  The  atrophy  not  unfrequently 
begins  in  the  lumbar  muscles  in  children,^  and  extends  to  those 
of  the  lower  extremities,  a  mode  of  invasion  which  is  probably 
due  to  the  preponderant  use  of  these  muscles  in  standing  and 
walking.  I  have  observed  a  similar  mode  of  invasion  in  a  collier, 
who  was  comp;^lled  to  work  in  a  bent  posture. 

Exposure  to  cold  and  wet  appears  to  be  of  itself  sufficient  to 
produce  the  disease.  Atrophy  of  the  hands  was  observed  by 
Richter^  in  a  man  who  suffered  from  severe  sweating  of  them 
and  who  was  accustomed  to  bathe  his  hands  in  ice-cold  water  and 
snow.  Dumdnil  *  observed  atrophy  of  the  lower  extremities  after 
long-continued  standing  in  water  while  fishing,  but  in  this  case  it 
is  doubtful  how  much  of  the  effect  is  to  be  attributed  to  exposure 
to  cold  and  how  much  to  excess  of  muscular  exertion.  The 
disease  is  doubtless  more  likely  to   be   developed  when  these 

1  Betz.    Prager  Vierteljahresschrift.    Bd.  XLIII.,  1854,  p.  104. 
^  See  Friedreich.    TJeber  progressive  muskelatrophie.     1873.    p.  208. 
^  Richter  (E.  H.).     Schmidt's  Jahrb.     Bd.  LXX.,  1857,  p.  177. 
"  Dum^nU.     "  Nouveaux  faits  relatifs  a  la  pathogenie  de  I'atrophie  musculaire 
graisseuse  progressive."    Gaz.  hebdom.,  1867,  pp.  442,  452,  and  469. 


SPINAL  COED   AND  MEDULLA  OBLONGATA.  941 

causes  are  combined.  Cases  arising  from  exposure  to  cold  are 
subject  to  neuralgic  or  rheumatic  pains  in  the  affected  parts, 
hence  these  cases  are  frequently  assumed  to  be  due  to  rheumatism. 
In  this  class  of  cases  the  invasion  is  often  sudden  and  accom- 
panied by  cramps  and  muscular  twitching  (Roberts),  and  the 
atrophy  is  more  apt  to  extend  to  the  muscles  of  the  trunk  than 
in  cases  due  to  overwork.  According  to  Dr.  Eoberts,  of  twenty- 
five  cases  attributed  to  overwork  eighteen  were  partial  and  only 
seven  general,  whereas  of  the  sixteen  cases  charged  to  the  agency 
of  cold  six  were  local  and  ten  general. 

Injuries  of  various  kinds  may  be  the  exciting  causes  of  this 
affection.  In  a  youth,  under  the  care  of  Dr.  Roberts,  who  ulti- 
mately died  from  implication  of  the  respiratory  muscles,  the  first 
symptom  of  atrophy  occurred  in  the  ball  of  the  right  thumb  six 
months  after  the  fall  of  a  bale  of  cotton  on  his  neck.  Cases 
similar  in  essential  particulars  are  recorded  by  Clarke  and  other 
authors.  Local  injury  to  some  of  the  muscles  of  the  body  is 
sometimes  followed  by  progressive  muscular  atrophy.  Fried- 
reich relates  a  case  in  which  the  hand  had  been  crushed,  and  the 
atrophy  afterwards  extended  progressively  upwards  over  the 
entire  upper  extremity,  and  was  finally  complicated  by  bulbar 
paralysis.  At  other  times  the  inflammatory  irritation  appears  to 
be  propagated  from  neighbouring  parts,  such  as  the  shoulder  and 
hip  joints,  and  the  disease  appears  at  times  to  have  been  caused 
by  cicatrices  or  suppurating  wounds.  These  cases  are  grouped 
by  Friedberg^  under  the  name  of  Tnyopathia  propagata. 

§  425.  Symptoms. — The  invasion  of  the  disease  is  slow  and 
insidious,  and  it  is  usually  in  existence  some  weeks  or  months 
before  its  presence  is  discovered.  The  patient  first  experiences 
some  dijSficulty  in  performing  certain  movements,  and  on  atten- 
tion being  directed  to  the  affected  limbs,  some  of  the  muscles 
are  discovered  to  be  more  or  less  wasted.  At  other  times, 
especially  when  the  disease  has  been  caused  by  exposure  to 
cold,  the  mode  of  invasion  is  attended  by  more  prominent 
symptoms.  Paroxysmal  pains,  like  those  of  rheumatism  or  of 
neuralgia,  are  felt  in  the  affected  limb  several  weeks  or  months 

»  Friedberg.  Pathologie  und  Therapie  der  Muskellahmung.  2  Aufl.,  Weimar, 
1862,  p.  22L 


942  SYSTEM  DISEASES  OF  THE 

before  the  atrophy  of  the  muscles  is  noticed,  and  when  once 
the  atrophy  begins  in  these  cases  it  proceeds  more  rapidly  and 
becomes  more  generalised  than  in  the  painless  variety. 

The  disease  usually  begins  in  one  of  the  upper  extremities, 
more  commonly  in  the  right,  either  in  the  interossei,  the  muscles 
of  the  thenar  and  hypothenar  eminences,  or  in  those  of  the 
shoulder.  Eulenburg^  says  that  when  the  disease  begins  in  the 
hand  the  interossei  (and  especially  the  first  interosseus)  are 
generally  attacked  before  the  muscles  of  the  ball  of  the  thumb ; 
while  the  contrary  opinion  is  held  by  Roberts^  and  Friedreich. 
The  opponens  pollicis  and  the  adductor  poUicis  are  the  first 
muscles  to  be  affected  in  the  ball  of  the  thumb,  while  the 
extensors,  abductor,  and  flexor  of  the  thumb  are  spared  for  a 
long  time,  or  may  escape.  In  some  few  cases  the  disease  begins 
in  the  muscles  of  the  shoulder,  and  in  these  the  deltoid  is  almost 
always  exclusively  affected  at  first.  When  the  atrophy  begins 
in  the  lumbar  muscles  and  lower*  extremities  children  are  said 
to  be  the  most  frequent  subjects  of  the  disease,  and  it  then 
frequently  simulates  pseudo-hypertrophic  paralysis,  which  will 
be  subsequently  described. 

During  the  progress  of  the  disease  certain  muscles  or  groups 
of  muscles  are  attacked  while  their  neighbours  are  spared,  and 
the  healthy  or  less  atrophied  muscles  overcome  the  resistance 
of  those  more  diseased,  so  that  characteristic  contractions  and 
deformities  are  produced.  The  disappearance  of  the  interossei  is 
shown  by  the  deep  furrows  which  appear  between  the  metacarpal 
bones,  the  thenar  and  hypothenar  eminences  are  flattened,  and 
the  disappearance  of  the  muscles  of  the  palm  brings  into  view  the 
diverging  flexor  tendons  which  are  stretched  between  the  wrists 
and  the  bulging  bases  of  the  fingers  (Roberts).  The  deformity  pro- 
duced by  paralysis  of  the  interossei  gives  to  the  hand  the  appear- 
ance of  the  talons  of  a  bird  of  prey ;  hence  it  has  been  called  the 
claw-shaped  hand  or  main  en  griffe  (Fig.  101).  This  deformity, 
however,  is  not  peculiar  to  progressive  muscular  atrophy, inasmuch 
as  it  may  be  caused  by  injury  to  the  ulnar  and  median  nerves.    In 

'  Eulenburg.  Art.  "  Vaso-motor  and  trophic  neuroses."  Ziemssen's  Cyclo- 
pffiJia  of  Medicine,  Vol.  XIV.,  1878,  p.  118. 

*  Eoberta  (W.).  Art.  "Wasting  palsy."  Reynolds'  System  of  Medicine,  Vol.  II., 
1868,  p.  169. 


tl:we  n 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  943 

consequence  of  the  atrophy  of  the  opponens  and  adductor  pollicis, 
the  thumb  is  extended  and  abducted  (Plate  II.,  1,  2,  3). 

When  the  forearm  is  affected,  the  anterior,  posterior,  or 
exterior  aspect  of  the  limb  is  flattened  according  as  the  flexors, 
extensors,  or  supinators  are  affected. 

When  the  muscles  of  the  shoulders  are  affected,  the  arms  may 
hang  by  the  side  or  rather  in  .front  of  the  patient,  as  if  they  were 
merely  attached  to  him  by  strings  and  did  not  belong  to  him  ; 
the  natural  rounded  configuration  of  the  shoulders  is  replaced 
by  a  hollow  in  which  the  palm  of  the  hand  may  be  lodged  under 
the  projecting  acromial  and  coracoid  processes  of  the  scapula, 
which  stand  out  in  relief.  The  biceps  and  the  other  muscles  of 
the  arm  may  also  waste,  so  that  the  limb  loses  its  roundness  and 
becomes  flattened,  and  the  humerus  appears  to  be  surrounded 
merely  by  the  skin. 

When  the  abdominal  muscles  are  affected,  the  lumbar  curve 
is  greatly  exaggerated  by  the  unopposed  action  of  the  erector 
spinae,  the  abdomen  is  loose  and  protruding,  but  the  thorax  is 
held  well  forwards,  so  that  a  plumb-line  let  drop  from  the  most 
prominent  of  the  spinous  processes  of  the  vertebrae  will  pass  well 
within  the  sacrum,  contrary  to  what  occurs  when  the  lumbar 
muscles  are  affected.  When  the  atrophy  is  unequally  distributed 
on  both  sides  of  the  body,  scoliotic  or  kyphotic  bending  of  the 
vertebral  column  may  be  produced.  When  the  erector  spinse 
and  extensors  of  the  thigh  are  implicated,  the  deformities  pro- 
duced, as  well  as  the  gait,  are  very  similar  to  those  seen  in 
pseudo-hypertrophic  paralysis,  and  it  is  unnecessary  to  describe 
them  here. 

When  the  lower  extremities  are  invaded,  deformities  occur 
corresponding  to  those  observed  in  the  upper  extremities,  but 
the  former  are  of  much  rarer  occurrence  than  the  latter.  The 
various  forms  of  club-foot  may  appear,  especially  the  paralytic 
pes  equino-varus. 

The  accessory  respiratory  muscles,  as  the  pectoralis  major, 
serratus  magnus,  trapezius,  &c,,  are  frequently  implicated ;  and 
although  the  wasting  and  loss  of  power  of  these  muscles  do  not 
directly  endanger  life,  yet  they  may  do  so  indirectly,  inasmuch 
as  a  slight  intercurrent  attack  of  bronchitis  may  lead  to 
asphyxia  since  the  inability  to  make  a  strong  expiratory  effort 


944  SYSTEM  DISEASES  OF  THE 

prevents  the  tubes  from  being  effectually  cleared  of  mucus.  In 
the  later  stages  of  the  affection,  the  diaphragm  and  the  inter- 
costal muscles  become  affected,  expectoration  fails,  mucus  collects 
in  the  tubes,  and  the  patient  dies  asphyxiated. 

The  facial,  lingual,  and  laryngeal  muscles,  as  well  as  the 
muscles  of  deglutition,  are  frequently  affected  towards  the  ter- 
minal period  of  the  disease ;  but  the  symptoms  caused  by  impli- 
cation of  these  muscles  will  be  described  as  labio-glosso-laryngeal 
paralysis. 

As  the  following  case,  which  is  carefully  reported  by  my 
friend  Dr.  Cullingworth,^  affords  a  good  example  of  progressive 
muscular  atrophy,  where  the  muscles  of  the  back  and  some  of 
the  muscular  groups  of  the  lower  extremities  are  affected,  I  shall 
quote  it  at  length : — 

Case  VI. — Charlotte  A ,  aged  forty-one,  admitted  into  St.  Mary's 

Hospital,  Manchester,  February  3, 1878.  She  is  married,  and  has  had  three 
living  children,  all  of  whom  died  in  infancy.  There  is  no  family  history  of 
nervous  disorder  or  of  impaii'ment  of  power  of  locomotion.  Her  father, 
an  intemperate  man,  died  of  chest  disease  at  the  age  of  thirty-six  ;  her 
mother  died  in  her  fiftieth  year  of  heart  disease.  Of  sis  brothers  and 
sisters,  two  died  in  infancy,  one  from  the  consequences  of  her  husband's 
ill-treatment,  and  three  are  living  in  good  health. 

She  worked  in  a  factory  from  the  age  of  nineteen  until  five  years  ago, 
having  had  constantly  two,  and  sometimes  more,  looms  under  her  charge. 
The  nature  of  her  work  necessitated  the  stooping  posture,  and  for  some 
years  this  had  been  a  painful  strain  to  her.  She  was  a  long  time  in 
straightening  herself  when  the  day's  labour  was  over,  and  the  process  was 
not  only  difficult  but  painful.  About  six  years  ago,  when  she  was  preg- 
nant of  her  last  child,  she  was  suddenly  seized  with  an  attack  of  uncon- 
sciousness while  at  her  work  ;  she  fell  down,  and  was  carried  imconscious 
home.  She  had  other  attacks  of  the  same  kind  both  before  and  after  her 
confinement,  and,  indeed,  had  one  shortly  before  her  admission.  Her  hus- 
band says  that  there  is  absolutely  no  warning,  that  she  frequently  hurts 
herself  in  falling,  that  she  foams  at  the  mouth  and  rolls  her  eyes,  but  that 
there  is  no  violent  struggling.  It  was  on  account  of  these  fits  that  her 
overlooker  advised  her,  for  her  own  safety  to  cease  work  several  years  ago. 
She  cannot  tell  exactly  when  the  peculiarity  in  walking  was  first  noticed, 
but  is  certain  that  she  has  had  difficulty  in  rising  from  a  chair  ever  since 
her  last  confinement.     This  difiiculty  has  gradually  increased. 

She  is  a  thin,  sallow-complexioned  woman,  of  average  height,  and  of 
feeble  intellectual  power.     Her  lips  become  markedly  livid  on  the  least 

'  CuUingworth  (C.  J.).    The  Medical  Times  and  aazette.    Vol.  II,  1878,  p.  121. 


SPINAL  CORD   AND  MEDULLA  OBLONGATA.  945 

exertion  or  exposure ;   tlie  whole  body  is  sensitive  to  cold.     There  is 
nothing  abnormal  in  the  condition  of  the  thoracic  or  abdominal  viscera. 

Examination  while  Standing. — The  head  is  erect,  and  movable  by  the 
patient  in  all  directions  ;  the  shoulders  are  somewhat  higher  than  usual  in 
a  woman  ;  the  upper  part  of  the  spine  is  carried  backwards  more  than 
usual  A  plimib-line  from  the  most  prominent  of  the  spines  of  the  upper 
dorsal  vertebrae  falls  an  inch  behind  and  away  from  the  sacrum.  The 
knees  are  very  slightly  bent  ;  the  feet  are  placed  firmly  on  the  ground, 
with  the  heels  touching,  the  toes  turned  outwards  and  extended  naturally. 
The  upper  extremities  present  no  appearance  of  muscular  deficiency,  and 
the  deltoids  are  prominent  and  weU  developed.  The  lower  extremities 
present  this  anomaly  :  that  while  the  thighs  are  thinner,  softer,  and  more 
flaccid  than  natural,  the  calves,  on  the  contrary,  are  of  a  size  quite  out  of 
proportion  with  the  muscular  development  of  the  rest  of  the  body.  The 
following  measurements  were  taken  : — Circimiference  of  upper  arm  below 
pectorals,  9|in.;  forearm  at  thickest  part,  9jin. ;  middle  of  thigh,  16in. ; 
thickest  part  of  calf,  14|in.  It  wiU  thus  be  seen  that  the  circumference 
of  the  calf  is  nearly  equal  to  that  of  the  middle  of  the  thigh.  This 
circumstance   gave  rise   to  a  suspicion  of  pseudo- hypertrophy,   and   a 

Fig.  199.  Fig.  200. 


Tig.  199  shows  the  position  assumed  by  the  scapulae  when  the  arms  are  extended 
forwards.  There  is  a  deep  sulcus  between  the  two  bones,  the  posterior  borders 
of  which  project  two  inches  from  the  costal  wall.  The  posterior  border  of  the 
left  scapula  is  parallel  with  the  median  line,  having  been  adjusted  by  the  action 
of  the  serratus  magnus,  whose  fibres  (passing  downwards,  outwards,  and  for- 
wards from  the  lower  angle)  are  seen  contracting  beneath  a  fold  of  skin.  This 
movement  of  adjustment  has  not  yet  taken  place  on  the  right  side,  where  the 
lower  angle  of  the  scapula  ia  nearer  the  vertebral  column,  a  Uttle  higher,  and 
altogether  more  prominent  than  on  the  opposite  side,  owing  to  the  unopposed 
action  of  the  deltoid ;  the  serratus  magnus,  being  in  a  condition  of  relaxation,  ia 
much  less  noticeable  on  this  (right)  side.  The  transverse  fibres  of  the  trapezius, 
passing  from  the  outer  half  of  the  spine  of  the  scapula  to  the  last  cervical  and 
first  dorsal  vertebrae,  are  well  seen  ;  with  these  fibres  the  upper  and  unaffected 
half  of  the  muscle  abruptly  terminates. 

Fig.  200  shows  the  appearance  of  the  back  when  a  healthy  subject  is  placed  in  the 
same  attitude.  The  scapulse  are  applied  so  closely  against  the  costal  wall  that, 
although  the  person  is  by  no  means  stout,  the  outline  of  the  bone  is  scarcely 
traceable.     The  lower  angle  is  in  the  axillary  line. 

VOL.  L  III 


946  SYSTEM  DISEASES  OF  THE 

minute  portion  of  muscle  was  withdrawn  from  the  calf  by  the  muscle- 
trocar,  and  kindly  examined  for  me  under  the  microscope  by  my  friend 
Dr.  Dreschfeld.  The  muscular  tissue  was  not  found  to  have  undergone 
any  change. 

As  the  patient  stands  at  ease,,  with  her  back  to  the  obserrer,  attention 
is  at  once  attracted  to  the  imusual  projection  of  the  posterior  borders  of  the 
scapulae.  They  stand  back  an  inch  from  the  posterior  chest- wall,  retaining 
their  parallelism  with  the  median  line,  and  leaving  a  fossa  between  them 
four  inches  in  breadth  and  an  inch  in  depth,  bounded  on  each  side  by  a 
wall  of  skin,  which  passes  perpendicularly  from  the  scapular  borders  to 
the  back  of  the  thorax.  The  condition  of  the  inter-scapular  muscles  can 
be  best  studied  when  the  arms  are  held  horizontally  forwards  {Fig  199,  and 
Plate  II.,  4  and  6).  The  spinal  borders  of  the  scapulae  then  project  back- 
wards to  a  distance  of  two  inches  from  the  chest- wall,  and  approach  within 
an  inch  and  a  half  of  each  other,  still  preserving  their  parallelism.  Between 
the  anterior  surface  of  the  scapulae  and  the  chest- waU  there  is  a  deep  groove 
posteriorly,  easily  admitting  the  tips  of  the  fingers  when  they  are  bent  over 
the  posterior  edge  of  the  scapula.  The  trapezius,  perfectly  developed  in 
its  clavicular  portion  and  in  the  upper  half  of  its  middle  third,  terminates 
abruptly  by  a  strong  bundle  of  fibres  stretching  across  from  the  spinous 
processes  of  the  laat  cervical  and  first  dorsal  vertebrae  to  the  outer  half  of 
the  spine  of  the  scapula.  There  is  not  a  trace  of  the  muscle  to  be  felt 
below  this  point.  Between  the  posterior  border  of  the  scapulse  and  the 
spinal  column  there  are  no  muscular  fibres  to  be  felt,  except  one  little  thin 
band  passing  to  the  middle  of  the  edge  of  the  scapula.  This  is  all  that 
remains  of  the  rhomboids.  The  latissimus  dorsi  has  also  disappeared,  and 
there  is  no  response  to  the  strongest  faradic  current  in  the  course  either  of 
this  muscle  or  of  the  lower  half  of  the  trapezius^  or  of  the  Fhomboid* 
except  in  the  slender  fasciculus  of  fibres  just  named.  On  the  other  hand, 
the  levator  anguli  scapvdse  and  sefratus  magnus  can  be  felt  to  contract 
forcibly,  and  they  respond  readily  to  a  moderate  current*  The  lower 
segment  of  the  latter  muscle,  passing  downwards  and  forwards  from  the 
lower  angle  of  the  scapula  to  the  lower  ribs,  stands  out  prominently  when 
the  arms  are  raised ;  and,  being  uncovered  by  the  latissimus  dorsi,  can  be 
grasped  underneath  the  sldn,,  which  is  raised  into  a  fold  by  the  contraction 
of  the  muscle.  The  deep  scapular  muscles  (supra-spinatus,  infra^spinatus, 
sub-scapularis,  teres  minor,  and  teres  major)  are  well  developed  and  easily 
defined.     The  pectoral  muscles  are  also  unaffected. 

The  patient  cannot  elevate  her  arms  vertically;  the  nearest  approach 
to  this  which  she  can  make  is  to  raise  her  elbows  until  they  are  on  a  level 
with  the  ears,  at  a  distance  of  about  nine  inches  from  the  head.  When 
this  position  is  assumed,  instead  of  the  scapulae  being  closely  applied  to  the 
chest- wall,  and  rotated  so  as  to  bring  the  lower  angle  outwards  and  forwards 
as  far  as  the  axillary  line,  the  posterior  borders  of  the  scapulae  are  brought 
into  actual  contact  with  each  other  at  their  upper  extremity,  slightly 
diverging  from  above  downwards,  so  that  the  lower  angles  are  two  inches 


SPINAL   CORD   AND  MEDULLA  OBLONGATA. 


947 


Fia.  201. 


apart.  The  anterior  face  of  the  scapula  is  in  the  meantime  one  inch  and 
three-quarters  behind  and  away  from  the  thorax.  When  the  arms  are 
stretched  out  horizontally  right  and  left,  the  posterior  borders  of  the 
scapulae  touch  each  other  both  at  their  upper  and  lower  angles,  on  a  plane 
one  inch  and  three-quarters  behind  the  chest-wall.  If  the  patient  places 
one  hand  upon  the  opposite  shoulder,  the  scapula  assumes  the  following 
position : — The  external  angle  is  raised  along  with  the  whole  shoulder,  the 
internal  angle  is  depressed,  the  inferior  angle  is  drawn  outwards,  the 
posterior  border  projects  an  inch  from  the  chest-wall  and  is  distant  from 
the  vertebral  column  three  inches  at  its  upper  end  and  four  inches  at 
its  lower.  When,  again,  the  shoulders 
are  drawn  back,  the  elbows  placed  by 
the  side  and  flexed,  so  that  the  fingers 
IJoint  upwards,  with  their  palmar  aspect 
directed  forwards,  the  posterior  borders 
of  the  scapulae  are  pressed  forcibly  toge- 
ther, closing  over  the  vertebral  column 
on  a  plane  two  inches  behind  it  (see 
Fig.  201). 

The  patient,  in  attempting  to  carry 
the  arm  behind  the  trunk,  cannot  rotate 
it  so  as  to  direct  the  posterior  aspect  of 
the  upper  arm  outwards,  or  carry  the 
upper  arm  from  the  plane  of  the  axilla 
towards  the  middle  line  of  the  back. 

Walking. — In  walking  there  is  a 
general  unsteadiness  of  gait,  but  no 
waddling.  The  knees  are  shghtly  flexed, 
and  the  head  and  shoulders  are  held 
well  back,  so  that  the  feet  are  always 
kept  in  front  of  the  patient.  The  mode 
of  progression  remains  unaltered  when 
the  patient  closes  her  eyes.  Ascending 
stairs  is  a  matter  of  extreme  difiBculty, 
and  it  is  exceedingly  painful  to  witness 
her  condition  of  exhaustion  and  lividity 
after  making  the  effort. 

Sitting. — When  about  to  sit  down 
she  steadies  herself  for  a  moment, 
grasps  her  thighs  firmly  with  her  hands, 
and  falls  suddenly  on  to  the  chair  as 
though  the  trunk  were  a  dead  weight. 
At  the  moment  and  in  the  act  of  sitting 
down,  the  trunk  is  involuntarily  thrown 
forwards  upon  the  thighs,  and  it  remains 
in  that  position  until  by  moving  the  feet 


Fig.  201  shows  the  patient  Char- 
lotte A ,  when  the  shoulders 

are  thrown  back  and  the  scapulae 
brought  together.  The  posterior 
borders  are  partially  in  contact 
on  a  plane  two  inches  behind  the 
costal  wall.  The  sharp  edge  of 
the  unaffected  half  of  the  trape- 
zius is  again  clearly  seen,  as  well 
as  the  inferior  segment  of  the  ser- 
ratus  magnus  on  each  side.  The 
levator  anguli  scapulae  is  acting 
more  powerfully  on  the  left  than 
the  right.  This  drawing  also 
shows  the  loss  of  rotundity  in  the 
gluteal  region,  and  the  remarkable 
contrast  between  the  hypertro- 
phied  calf  and  the  attenuated 
muscles  of  the  thigh. 


948      SYSTEM  DISEASES  OF  THE 

forward  and  planting  them  firmly,  and  by  tlien  grasping  the  knees,  she 
pushes  up  the  trunk  into  the  erect  posture  "  by  force  of  arms." 

Rising  from  the  Sitting  Posture. — She  rises  from  the  sitting  posture 
with  great  difficulty,  and  in  the  following  manner  : — Compressing  her  lips, 
she  separates  the  feet  widely,  and  grasps  both  her  knees  ;  she  then  flexes 
the  trunk  upon  the  thighs  imtil  the  trunk  is  horizontal,  and  raises  the 
buttocks  from  the  chair  by  a  movement  of  extension  at  the  knee.  In  this 
stooping  attitude  she  shuffles  away  from  the  chair  until  she  reaches  some- 
thing to  lay  hold  of — mantelpiece,  table,  or  bystander — when,  having  rested 
for  a  moment,  she  raises  the  hands,  one  by  one,  from  the  knees,  and  clutches 
firmly  the  object  near  which  she  has  halted.  Then  very  slowly  and  with 
great  efibrt,  keeping  the  back  stiff  and  straight,  she  raises  herself  by  means 
of  the  arms  into  the  upright  position.  The  mode  in  which  she  rises  from 
the  floor  is  even  more  painful  to  witness.  Placing  her  hands  on  the  ground 
in  front  of  her,  she  first  of  all  scrambles  on  to  her  hands  and  knees.  In 
this  postiire  she  makes  her  way  to  the  nearest  available  article  of  furniture, 
seizing  which,  she  regains  her  feet.  The  tnmk,  however,  is  still  horizontal, 
and  it  is  the  tremendous,  and  for  a  long  time  futile,  efforts  that  she  now 
makes  to  straighten  herself  that  constitute  the  most  distressing  part  of  the 
performance.  Striving  to  obtain  a  firm  purchase  with  her  feet,  the  knees 
being  fully  extended,  the  feet  slip  backwards  time  after  time.  Eventually, 
after  violent  exertions,  which  leave  her  exhausted  and  breathless,  she 
accomplishes  her  task. 

Flexion  of  Thigh  upon  Pelvis,  Sc. — When  lying  in  bed  horizontally  upon 
the  back,  she  is  able  to  flex  the  leg  upon  the  thigh,  and  the  thigh  upon  the 
tnmk,  so  long  as  the  heel  remains  upon  the  bed  ;  but  when  the  leg  is  fully 
extended  she  is  luiable  to  lift  the  heel  a  single  inch  from  the  plane  of  the 
bed.  As  she  sits,  with  the  knees  flexed,  she  cannot  raise  the  foot  from  the 
groimd  ;  but  the  movements  of  adduction  and  abduction  are  accomplished 
fairly  well.  She  crosses  one  thigh  over  the  other  by  the  following 
manoeuvre  : — Supposing  the  right  thigh  is  to  be  crossed  over  the  left,  the 
left  knee,  bent  to  an  acute  angle,  is  adducted  and  pushed  under  the  right 
knee,  which  latter  is  thus  lifted  up  and  carried  over  to  the  left  side,  resting 
upon  its  fellow. 

Ankle. — The  movements  at  the  ankle-joint  are  performed  without 
difficulty. 

Owing  to  the  kindness  of  Mr.  Cullingworth  I  have  had 
repeated  opportunities  of  examining  this  woman,  and  the  only 
addition  I  should  like  to  make  to  his  valuable  report  of  the 
case  is  to  draw  attention  to  the  gait  of  the  patient,  especially- 
noting  the  points  in  which  it  differs  from  the  gait  characteristic 
of  pseudo-hypertrophic  paralysis. 

In  the  case  of  this  woman  the  feet  are  held  close  to  each  other,  and,  as 
Mr.  Cullingworth  observes,  the  gait  is  not  waddling.     In  walking  the  head 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  949 

does  not  deviate  laterally  from  the  middle  line  during  the  transference  of 
the  centre  of  gravity  from  the  active  to  the  passive  leg,  but  it  may  be 
observed  to  advance  by  a  series  of  vertical  curves.  In  his  remarks  on  the 
case  Mr.  Cullingworth  observes  that  the  patient  is  unable,  when  lying 
horizontally  on  her  side  with  the  legs  extended,  to  separate  her  thighs, 
thus  showing  that  the  gluteus  medius  and  minimus  are,  at  least  to  some 
estent,  affected  by  paralysis.  On  placing  one's  own  hands  over  the  pelvis 
of  the  patient,  one  being  held  on  each  side  immediately  above  the  tro- 
chanter of  the  femur,  it  is  felt  that  the  gluteus  medius  on  the  side  of  the 
active  leg  does  not  contract  during  locomotion.  The  consequence  is  that, 
instead  of  the  pelvis  on  the  side  of  the  passive  leg  being  sUghtly  elevated 
as  in  health,  by  the  contraction  of  the  gluteus  medius  of  the  opposite  side, 
so  as  to  aUow  the  leg  to  swing  forwards,  it  is  distinctly  felt  to  drop  on  that 
side  to  a  lower  level.  The  pelvis,  therefore,  forms  a  more  or  less  acute 
angle  with  the  active  leg  instead  of,  as  in  health,  forming  an  obtuse  angle 
with  it.  It  is,  however,  maintained  in  a  nearly  horizontal  position  by  the 
fact  that  the  active  leg  itself  slants  downwards  and  inwards  from  the  hip- 
joint.  The  line  of  gravity  passes  through  the  pelvis  about  its  middle  ;  and 
in  order  that  it  may  pass  through  the  arch  of  the  foot  of  the  active  leg,  the 
latter  must  occupy  a  position  directly  below  the  middle  of  the  pelvis,  and 
consequently  the  hip  of  that  side  projects  outwards.  The  passive  leg  is 
prevented  from  swinging  forwards  with  the  normal  pendulum  motion,  inas- 
much as  the  hip-joint  on  that  side  becomes  lower  when  the  leg  is  raised  off 
the  ground,  instead  of  being  elevated  by  contraction  of  the  gluteus  medius 
of  the  opposite  side  as  in  health.  The  necessary  elevation  of  the  passive 
foot  is  obtained  by  strong  flexion  of  the  thigh  upon  the  body,  so  that  the 
legs,  as  described  by  Mr.  Cullingworth,  appear  to  be  in  advance  of  the 
body.  The  alternate  projection  of  the  hip  on  the  side  of  the  active  leg,  and 
the  alternate  falling  down  of  the  hip  on  the  side  of  the  passive  leg  during 
successive  steps,  render  the  gait  of  this  patient  totally  unhke  that  which  is 
so  characteristic  of  pseudo-hypertrophic  paralysis.  It  may  also  be  stated 
that  the  serratus  magnus  is  now  completely  paralysed  and  atrophied  on 
both  sides,  and  this  helps  to  give  to  the  scapulae  the  winged  appearance 
observed  in  Plate  II.,  Figs.  5  and  6.  This  patient  has  now  been  under 
observation  for  a  period  of  five  years,  and  with  the  exception  of  the  impli- 
cation of  the  serrati  muscles  the  atrophy  has  made  no  further  perceptible 
advance. 

The  loss  of  muscular  power  keeps  pace  with  the  atrophy,  and 
is,  as  a  rule,  directly  in  proportion  to  the  degree  of  the  latter, 
and  so  long  as  any  muscular  fibres  are  left,  they  can  be  made  to 
contract  by  voluntary  effort.  For  a  very  long  time,  indeed,  the 
various  movements  are  capable  of  being  performed,  although 
with  much  diminished  power,  and  it  is  only  in  the  last  stage  of 
the  affection  that  complete  immobility  of  the  limb  is  produced. 


950  SYSTEM  DISEASES   OF   THE 

When  once  a  muscle  is  attacked,  it  wastes,  as  a  rule,  in  a 
perfectly  uniform  manner,  but  in  some  few  cases  a  portion  only 
of  the  length  of  the  muscle  undergoes  atrophy,  while  the 
remainder  maintains  its  volume,  and,  to  a  considerable  extent 
at  least,  its  motor  power  also.  In  a  patient  under  my  care  the 
upper  third  of  each  deltoid  is  so  completely  atrophied  that  the 
edge  of  the  acromion  process  may  be  felt  underlying  the  skin, 
but  the  lower  two  thirds  is  not  perceptibly  wasted.  When  the 
patient  raises  his  arm  to  a  horizontal  position,  a  deep  depression 
is  seen  over  the  shoulder  joint  caused  by  the  disappearance  of 
the  upper  portion  of  the  muscle,  whilst  the  lower  and  larger 
portion  forms  a  protuberant  mass,  which  can  be  felt  by  the  hand 
laid  over  it  to  be  strongly  contracted.  In  another  case  I  have 
seen  the  middle  third  of  each  of  the  biceps  muscles  completely 
atrophied,  whilst  the  upper  and  lower  thirds  had  maintained  a 
fair  volume.  In  other  cases  the  loss  of  motor  power  apparently 
much  exceeds  the  loss  of  muscular  substance,  but  in  these  the 
bulk  of  the  muscle  is  maintained  or  even  increased  by  an  inter- 
stitial fatty  hyperplasia,  while  the  individual  muscular  fibres  are 
atrophied,  so  that  the  disproportion  between  the  loss  of  muscular 
power  and  the  loss  of  muscular  substance  is  only  apparent  and 
not  real.  This  condition  will  be  more  fully  described  when  the 
closely-allied  disease  called  pseudo-bypertrophic  paralysis  comes 
under  consideration. 

The  reflex  movements  are  occasionally  exaggerated  in  the 
early  stage  of  the  disease,  but  they  become  diminished  as  the 
muscular  atrophy  advances. 

The  electrical  reaction  of  the  atrophied  muscles,  as  a  rule, 
corresponds  closely  with  the  diminished  volume  of  the  muscles 
and  the  loss  of  voluntary  power.  The  normal  faradic  contrac- 
tility is  maintained  until  the  muscle  has  undergone  a  high 
degree  of  atrophy,  and  it  is  only  in  the  last  stage  of  muscular 
atrophy  that  the  excitability  is  diminished  or  abolished.  It  need 
scarcely  be  added  that,  although  the  faradic  excitability  is  not 
diminished,  yet  the  energy  of  contraction  becomes  weaker  and 
weaker  in  proportion  as  the  contractile  elements  of  the  muscle 
disappear.  The  faradic  excitability  of  the  nerve-trunks  is  re- 
tained longer  than  that  of  the  muscle,  and  both  disappear  some 
time  before  complete  loss  of  voluntary  power  occurs.     Galvanic 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  951 

muscular  contractility  usually  remains  normal  for  a  long  time, 
although  the  energy  of  the  contraction  diminishes  in  proportion 
to  the  degree  of  atrophy,  so  that  stronger  currents  are  required 
to  produce  a  minimum  contraction  (Eulenburg).  The  galvanic 
excitability  of  the  nerve-trunks  also  remains  unimpaired  for  a 
long  time.  A  case  has  recently  been  recorded  by  Bernhardt,^  in 
which  the  affected  nerves  and  muscles  gave  very  exceptional 
reactions  to  both  currents.  The  atrophied  muscles  were  those  of 
the  left  hand  and  those  of  the  ulnar  border  of  the  left  forearm. 
The  faradic  excitability  of  the  ulnar  nerve  was  increased,  or  at 
least  equal  to  that  of  the  sound  side.  The  galvanic  excitability 
of  the  nerve  was  decidedly  increased,  and  manifested  qualitative 
changes.  The  same  kind  of  reactions  were  obtained  to  both 
currents  applied  directly  to  the  muscles  of  the  forearm.  The  reac- 
tions of  the  interossei  muscles  were  diminished  to  both  currents. 
Rosenthal^  has  directed  attention  to  the  fact  that  the  nerve- 
trunks  behave  differently  at  different  points  in  their  course, 
so  that  while  electrical  stimulation  applied  to  a  portion  situated 
near  the  centre  may  produce  normal  effects,  the  reactioas 
may  be  diminished,  or  entirely  wanting  when  a  more  peripheral 
tract  is  stimulated.  Slight  qualitative  changes  in  the  muscular 
reaction  may  attend  the  ultimate  stage  of  atrophy. 

Fibrillary  contractions  of  the  affected  muscles  are  frequently 
observed  during  the  entire  active  stage  of  the  disease.  These 
consist  of  vibratory  tremors  or  quivering  of  the  muscular  fibres. 
They  occur  spontaneously,  but  may  be  provoked  by  gently 
tapping  the  surface,  by  exposing  to  the  air  parts  which  are 
usually  covered,  by  electrical  excitation,  and  by  active  or  passive 
movements  of  the  affected  muscles.  These  fibrillary  contrac- 
tions are  sometimes  the  earliest  symptoms  of  a  fresh  advance  of 
the  disease  into  parts  previously  unaffected,  and  they  disappear 
altogether  when  the  atrophy  has  reached  an  extreme  degree,  or 
when  its  progress  is  arrested.  During  the  stage  of  active  fibrillary 
contractions  the  idio-muscular  contractility  may  be  so  much 
increased  that  the  slightest  tap  on  the  tendons,  fasciae,  neighbour- 
ing bones,  or  on  the  bellies  of  the  affected  muscles  themselves, 

'Bernhardt.  "  Abnorme  electrische  Erregbarkeits-verhaltnisse  in  einem  Talle 
von  progressiver  Muskelatrophie."    Zeitschrift  fiir  klin.  Med.,  Bd.  V.,  1882,  p.  127. 

^  Rosenthal.  Treatise  on  the  diseases  of  the  nervous  system.  New  York,  1879. 
p.  286. 


952  SYSTEM  DISEASES  OF  THE 

induces  widely  diffused  contractions,  such  as  is  frequently  observed 
in  advanced  cases  of  phthisis.  In  these  cases  a  slight  tap  on  the 
lower  end  of  the  radius,  for  instance,  may  cause  almost  the  whole 
of  the  muscles  of  the  forearm  and  arm,  as  well  as  the  pectoral 
muscles,  to  enter  into  contraction,  and  the  forearm  may  be 
jerked  upwards  just  as  occurs  in  cases  of  spasmodic  paralysis. 
When  the  paralysis  extends  to  the  lower  extremities  the  knee- 
jerk  may  be  so  lively  as  to  give  rise  to  considerable  difficulties 
in  diagnosis. 

Occasionally  clonic  or  tonic  contractions  of  entire  muscles,  or 
groups  of  muscles,  may  occur,  accompanied  by  intense  pain, 
analagous  to  the  well-known  cramp  of  the  calf. 

The  seKisibility,  as  a  rule,  is  entirely  unaffected.  In  some 
cases,  however,  the  atrophy  of  the  muscles  is  preceded  by 
paroxysms  of  pain  in  the  affected  parts.  At  times  the  pains 
follow  the  course  and  distribution  of  single  nerve  trunks,  as  that 
of  the  median  and  ulnar  nerves,  but  at  other  times  the  pains 
appear  to  have  their  origin  in  the  sensory  nerves  of  the  muscles. 
In  the  latter  case  compression  of  the  affected  muscles,  as  well  as 
active  and  passive  movements  of  them,  provokes  or  aggravates 
the  pain,  and  in  some  cases  the  electro-muscular  sensibility  seems 
to  be  increased.  In  the  later  stages  of  the  affection  a  moderate 
degree  of  anaesthesia  may  be  present,  especially  in  the  hands^  and 
tips  of  the  fingers,  in  the  form  of  blunting  of  common  sensation. 
The  farado-cutaneous  sensibility  may  also  be  diminished,  and 
complete  analgesia  of  circumscribed  areas  is  not  uncommon, 
whilst  the  patient  may  experience  sensations  of  cold  and  numb- 
ness in  the  finger  tips,  as  well  as  formication,  and  other 
parsesthesise  in  the  hands  and  feet. 

Vaso-motoT  disturbances  of  various  degrees  and  extent  may 
occur  in  the  affected  regions.  In  the  beginning  the  temperature 
of  the  affected  extremities  is  increased.  BaerwinkeP  found  an 
elevation  of  from  0"3°  to  1°  R  in  one  case,  and  Frommann^ 
found  in  the   side  first  attacked  a  rise  of  0"2°  or  0'3°  C,   as 

'  Landois  and  Mosler.  "Neuropathologischen  Studien."  BerL  klin.  Wochen- 
schr.,  1868,  p.  458. 

2  Baerwinkel.  "  Ein  Fall  von  Atrophia  muscularis  progressiva  mit  Betracht- 
ungen  iiber  deren  Natur."    Prager  Vierteljahresschrift,  Bd.  LIX.,  1858,  p.  133. 

^  Frommann.  "Fall  von  Atrophie  Muse,  progress."  Deutsche  Klinik,  1857, 
pp.  317  and  324. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  953 

compared  with  the  opposite  side.  In  more  advanced  stages  the 
temperature  is  not  raised,  and  at  a  still  later  period  a  distinct 
lowering  occurs  which,  according  to  Rosenthal^  and  Jaccoud,^ 
may  amount  to  3°  or  4°  C.  below  the  normal. 

The  affected  parts  are  cold  and  pale,  and  this  is  especially 
likely  to  occur  in  the  hands.  This  local  ischsemia  is  followed  by 
relaxation  of  the  vessels,  and  consequent  warmth  and  redness  of 
the  affected  part.  An  excessive  sweating  (hyperidrosis)  of  a 
generalised  character  has  been  described  by  Frommann  and 
Friedreich*  as  occurring  in  the  later  stages  of  the  affection, 
but  whether  this  is  due  to  vaso-motor  disturbance  is  unknown. 

Trophic  disturbances  occur  at  times  in  other  tissues  in  addi- 
tion to  the  muscular  affection.  The  skin  is  not  unfrequently 
implicated ;  and  in  these  cases  the  epidermis,  cutis,  and  sub- 
cutaneous tissues  are  affected.  The  affection  of  the  skin  may 
be  entirely  wanting,  and  scarcely  ever  reaches  a  high  degree, 
even  when  the  muscular  disease  is  far  advanced.  Painful 
swellings  of  the  joints  have  been  observed  in  the  early  stages  of 
the  disease.*  These  swellings  (arthritis  nodosa)  generally  occur 
in  the  phalangeal  joints,  and  are  in  all  probability  closely  related 
to  the  arthropathies  of  tabes  dorsalis,  except  that  the  latter  are 
more  frequent  in  the  large  than  in  the  small  joints. 

Oculo-pupillary  symptoms  are  on  rare  occasions  observed  in 
this  disease.  They  consist  of  flattening  of  the  cornea^  and  con- 
traction and  sluggish  reaction  to  light  of  one  or  both  pupils,^  these 
symptoms  being  most  probably  caused  by  implication  of  the  sym- 
pathetic fibres  in  the  cilio-spinal  region  of  the  cord.  A  case  of 
progressive  muscular  atrophy  is  under  my  own  care  at  present,  in 
which  the  pupils  are  very  small,  but  they  contract  readily  to  light. 

In  the  early  stage  of  progressive  muscular  atrophy  the  patient 

'  Rosenthal  "  Zwei  Falle  von  progressiver  Muskelatrophie,  der  erste  Fall  mit 
SectionsbefunA"    Allg.  med.  Central-Zeitung,  1871,  p.  73. 

*  Jaccoud.    Legons  de  la  clinique  medicale.    Paris,  1867.    p.  343. 
^Friedreich.     "  Ueber  progressive  Muskelatrophie."    Berl.,  1873.    p.  183. 

*  Eemak  (E.),  Oesterr.  Zeitschrift  fur  prakt.  Heilkunde,  1862,  pp.  1  and  29 ; 
and  "  Neurologische  und  electro-therapeutische  Ergebnisse,"  Allg.  med.  Central- 
Zeitung,  Berl.,  1863,  p.  153. 

*  Voisin.  "Atrophie  musculaire  progressive— phenomenes  oculo-pupillaires." 
Gaz.  hebdom.,  1863,  p.  607. 

*  Schneevogt.  "Ueber  Paralysis  progressiva  atrophica,"  Neder.  Lancet,  1864, 
Sept.  and  Oct. ;  Canstatt's  Jahresb.,  1855,  Bd.  III.,  p.  74.  And  Baerwinkel. 
Prager  Vierteljahresschrift,  Bd.  LIX.,  1858,  p.  133. 


954  SYSTEM  DISEASES   OF  THE 

may  complain  of  chills,  and  there  may  be  a  continuous,  though 
slight,  increase  of  temperature,  which  lasts  for  days  or  months. 
This  febrile  condition  may  sometimes  be  associated  with  arthritis 
nodosa,  and  may  probably  be  due  to  the  affection  of  the  joints 
(Remak).  In  the  later  stages  of  the  disease  transitory  or  per- 
manent elevations  of  temperature  may  occur,  which  are  perhaps 
due  to  such  complications  as  diseases  of  the  lungs  or  acute  bed- 
sore.    No  constant  changes  have  been  found  in  the  urine. 

§  426.  Course  and  Duration. — The  course  of  progressive 
muscular  atrophy  is  essentially  chronic.  It  may  at  times  be 
permanently  arrested  after  a  certain  group  of  muscles  is  de- 
stroyed, but  it  may  progress  steadily  until  nearly  all  the  voluntary 
muscles  are  implicated  and  the  unfortunate  patient  is  reduced 
to  such  utter  helplessness  that  he  cannot  raise  a  hand  to  feed 
himself  or  turn  himself  in  bed.  The  advance  of  the  disease  is 
seldom  continuous  even  when  it  is  progressive,  but  is  interrupted 
by  repeated  remissions.  These  may  extend  over  a  few  weeks, 
months,  or  years.  Dr.  Roberts^  thinks  that  the  cases  caused  by 
over  exercise  of  the  muscles  nearly  always  terminated  in  per- 
manent arrest  of  the  affection  after  the  destruction  of  one  or  more 
groups  of  muscles;  while  cases  which  were  caused  by  exposure  to 
cold,  or  in  which  a  decided  hereditary  predisposition  could  be 
traced,  showed  a  greater  tendency  to  a  progressive  course  and  a 
fatal  termination.  In  some  few  cases  the  atrophied  muscles  may 
by  treatment  be  restored  to  their  former  bulk,  but  they  usually 
remain  disabled  to  a  more  or  less  extent  for  the  remainder  of  life. 

The  duration  of  the  disease  is  very  variable  and  uncertain. 
In  twenty-eight  cases  analysed  by  Dr.  Roberts  the  mean  duration 
was  thirty-eight  months  ;  of  these  four  cases  ended  in  recovery, 
their  mean  duration  being  fourteen  months ;  in  thirteen  cases 
the  disease  was  arrested  with  a  mean  duration  of  twenty-seven 
months,  and  the  remaining  eleven  cases  died  with  a  mean  dura- 
tion of  the  disease  of  upwards  of  five  years. 

§  427.  Morbid  Anatomy. — The  essential  anatomical  changes 
found  on  post-mortem  examination  of  those  who  have  died  from 

^  Roberts  (W.).  Art.  "Wasting  Palsy."  Reynolds'  System  of  Medicine,  Vol.  II., 
1868,  p.  172. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA,  955 

progressive  muscular  atrophy  are  confined  to  the  muscles,  the 
spinal  cord,  and  the  nerves. 

The  muscles  of  the  affected  regions  are  wasted  in  various 
degrees,  and  even  different  parts  of  the  same  muscle  may  present 
differences  in  the  degree  to  which  the  atrophy  has  extended.  A 
small  portion  of  an  affected  muscle  may,  indeed,  retain  its  normal 
bulk  and  appearance,  while  the  rest  is  reduced  to  a  fibrous  band. 
The  altered  muscles  are  generally  of  a  pale  red  or  rose  colour, 
while  at  other  times  they  may  be  buff  or  ochre,  and  streaks  of 
adipose  tissue  may  be  seen  to  run  in  lines  between  the  fibres. 

The  early  investigators  (Meryon,  Duchenne,  Cruveilhier, 
Wachsmuth,  and  Valentiner)  regarded  the  muscular  changes 
as  being  the  result  of  fatty  degeneration  of  the  fibres,  with 
secondary  disappearance  of  the  sarcolemma ;  but  the  labours 
of  recent  investigators  (Robin,  Friedberg,  Foerster,  Schiippel, 
Hayem,  and  Friedreich)  have  shown  that  the  fatty  metamor- 
phosis of  the  primitive  fibres  is  a  secondary  result  of  a  previous 
inflammatory  change.  The  first  changes  begin  in  the  perimysium 
internum,  as  a  hyperplastic  growth  of  the  interstitial  connective 
tissue  in  its  finest  ramifications  among  the  single  primitive 
bundles.  Swelling  and  multiplication  of  the  muscular  corpuscles, 
along  with  proliferation  of  their  nuclei,  may  be  observed,  and  at 
times  parenchymatous  granular  cloudiness  of  the  transverse 
striped  fibrillary  substance.  Friedreich  says  that  he  has  observed 
hypertrophied  muscular  fibres  along  with  a  dichotomous  or 
trichotomous  division  of  their  fibres.  Wasting  of  the  muscular 
substance  goes  on  side  by  side  with  increase  of  the  interstitial 
tissue,  a  process  which  ultimately  leads  to  a  fibrous  degeneration 
or  true  cirrhosis  of  the  muscle.  A  development  of  fat  may  take 
place  within  the  hyperplastic  connective  tissue,  leading  to  a 
pseudo-hypertropy  of  the  muscle. 

The  condition  of  the  spinal  cord  and  of  the  anterior  spinal 
nerves  roots  has  been  examined,  according  to  Eulenburg,  in 
forty-nine  cases,  and  out  of  these  positive  changes  have  been 
found  in  thirty-four,  while  in  fifteen  the  results  were  negative. 
If,  however,  the  special  methods  and  special  skill  which  are 
required  for  conducting  the  examination  of  the  spinal  cord  be 
taken  into  consideration,  too  much  weight  need  not  be  attached 
to  the  negative  statements.     In  the  hands  of  experts  in  the 


956  SYSTEM  DISEASES   OF  THE 

present  day  changes  are  almost  always  found  in  the  cord,  hence 
the  negative  results  of  the  older  observers  may  be  fairly  attri- 
buted to  defective  methods.  Cruveilhier  ^  was  the  first  to  draw 
attention  to  the  condition  of  the  anterior  roots  of  the  nerves  in 
this  disease.  In  the  body  of  the  showman,  Le  Compte,  who 
died  from  progressive  muscular  atrophy  of  five  years'  duration, 
he  found  that  the  anterior  roots,  especially  in  the  cervical  region, 
were  remarkably  small  as  compared  with  the  posterior  roots ; 
and  in  a  second  case,  observed  by  him,  a  similar  condition  was 
found.  In  these  cases  the  brain,  cord,  and  posterior  roots  were 
stated  to  be  normal.  Soon  afterwards  Reade^  and  DumdniP 
found  atrophy  of  the  anterior  roots  in  cases  of  the  disease,  and 
similar  changes  have  since  then  been  found  by  Clarke,*  Vulpian,^ 
Trousseau,^  Lnys,^  Jaccoud,®  Rosenthal,^  von  Recklinghausen,^" 
Hayem,^^  Charcot  and  Joffroy,^^  Friedreich ,^^  and  many  others. 
The  anterior  nerve  roots  have  been  found  normal  in  cases 
reported  by  Clarke,^*  Frommann,^^  Friedreich,^^  and  Frerichs.^  It 
may,  therefore,  be  concluded  that  the  atrophy  of  the  anterior 
roots  is  not  the  essential  morbid  change. 

In  1855  Valentiner^^  found  a  central  softening  of  the  grey 

1  Cruveilhier.  "  Sur  la  paralysie  musculaire  progressive  atrophique."  Arch, 
g^n.  de  med.,  Janvier,  1856,  p.  12. 

-  Reade.  "Contributions  to  the  pathology  of  the  spinal  marrow."  Dublin 
Quarterly  Journal  of  Medical  Science,  Nov.,  1856,  p.  399. 

^Dum^nil.  Gaz.  hebdom. ,  No.  25,  1859;  Canstatt's  Jahresb.,  1859,  Bd.  III., 
p.  100  ;  and  Gaz.  hebdom.,  1867,  pp.  422,  452,  et  469. 

*  Clarke  (L.)  and  EadcliEEe.  British  and  Foreign  Medico-Chir.  Eeview. 
Vol.  XXX.,  1862,  p.  215. 

"  Viilpian.     L'llnion  M^dicale.     1863.    No.  49. 

^  Trousseau  (A.).  Lectures  on  Clinical  Medicine,  New  Syd.  Soc,  Lond.,  1868, 
Vol.  I.,  p.  301. 

^  Luys.    Gaz.  m(^d.  de  Paris.     1860.     No.  32. 

*  Jaccoud.     Gaz.  des  Hopit.    1863.     No.  6. 

*  See  Rosenthal.     Op.  cit.,  p.  281. 

*"  von  Recklinghausen.    Wiener  med.  Presse.     1869.     p.  628. 

' '  Hayem.  "  Note  sur  un  cas  d'atrophie  musculaire  progressive  avec  Msions  de 
la  moelle."    Arch,  de  physiologie.  Tome  II.,  1869,  pp.  263  and  391. 

^^  Charcot  and  Jofifroy.  "Deux  cas  d'atrophie  musculaire  progressive _ avec 
lesions  de  la  substance  grise  et  des  faisceaux  anterolateraux  de  la  moelle  epiniere." 
Arch,  de  physiol.,  Tome  II.,  1869,  p.  356. 

1^  Friedreich.     Op.  cit.  (Fallen  I.  und  II.),  p.  11  et  seq. 

1*  Clarke  and  Gairdner.     Beale's  Arch,  of  Medicine.     Vol.  III.,  Oct.,  1861,  p.  1. 

i^Frommann.    Deutsche  Klinik.    Nos.  33,  34.     1857. 

1  ^  Friedreich.     Op.  cit.  (Fallen  IV.,  X.,  XVIL),  pp.  21,  37,  and  44. 

'^  See  Swarzenski.    Die  progressive  Muskelatrophie.     Diss.,  1867. 

>  ^  Valentiner.  "  Ein  Beitrag  zu  der  Lehre  von  den  sogenanuten  Paralysie  muscu- 
laire progressive."    Prager  Vierteljahresschrift,  Bd.  XL VI.,  1855,  p.  15. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  957 

substance  in  the  neighbourhood  of  the  lowest  cervical  and  the 
uppermost  dorsal  nerves ;  and  Schneevogt^  also  found  a  soften- 
ing of  the  cord  from  the  fifth  cervical  to  the  second  dorsal  nerves. 
Frommann^  observed  changes  in  the  anterior  column  and  anterior 
commissure  extending  from  the  medulla  oblongata  downwards. 
Luys,'  however,  was  the  first  to  direct  attention  to  the  morbid 
changes  in  the  grey  substance.  A  man,  the  subject  of  advanced 
atrophy  of  the  muscles  of  the  left  hand  and  forearm,  along  with 
slight  atrophy  of  the  muscles  of  the  right  hand,  having  died  of 
pneumonia,  the  spinal  cord  at  the  autopsy  appeared  healthy  to 
the  naked  eye,  but  microscopical  examination  showed  increase 
of  the  capillary  vessels  in  the  grey  substance  of  the  cervical 
enlargement.  The  walls  of  the  vessels  were  thickened  and 
surrounded  with  granular  exudation,  which  extended  into  the 
adjacent  tissues.  Many  corpora  amylacea  were  scattered  through 
the  grey  substance.  A  considerable  number  of  the  ganglion 
cells  of  the  anterior  horns  had  disappeared  in  the  part  affected, 
and  were  replaced  by  granular  masses,  and  of  the  remaining 
cells  some  were  degenerated,  of  a  brownish  colour,  full  of  dark 
granules,  and  destitute  of  processes.  The  degeneration  affected 
principally  the  left  anterior  cornu,  corresponding  with  the  seat 
of  the  muscular  atrophy.  The  anterior  nerve  roots  on  the  left 
side,  corresponding  to  the  disease  in  the  anterior  horn,  were 
atrophied.  Six  cases  have  since  been  described  by  Lockhart 
Clarke,*  confirming,  in  all  essential  respects,  the  observations 
of  Luys  ;  and  similar  observations  have  been  made  by  Dumdnil,^ 
Hayem,^  Charcot  and  Joffroy/  and  Pierret  and  Troisier.^ 

In  a  case  described  by  Charcot  the  ganglion  cells  of  the  left 
anterior  grey  horn  (Fig.  202,  A)  could  still  be  distinguished, 
but  were  observed  to  be  in  an  advanced  stage  of  atrophy.     In 

'  Schneevogt.    Nederland.  Lancet.     Sept.  en  Oct.,  1854. 
'  Frommann.     Loc.  cit. 

*  Luys.     Gaz.  m(^dical  de  Paris.     No.  32.     1860. 

*  Clarke  and  Cooper.  Medico-Chirurgical  Transactions.  Vol.  XLIX. ,  1866, 
p.  171.  And  Clarke  and  Jackson.  Medico-Chirurgical  Transactions.  V^ol.  L., 
1867,  p.  489. 

*  Dum^nil.    Gaz.  hebdom.    1867.     p.  453. 

*  Hayem.     Archiv.  de  physiologic.     Tome  II.,  1867,  pp.  263,  391. 

'  Charcot  and  Joffroy.  Arch,  de  physiol.  Tome  II.,  1869,  p.  356.  And  Charcot. 
Legons  sur  les  maladies  du  Systeme  Nerveux.    Tome  II.,  2nd  Edit.,  1877,  p.  205. 

*  Pierret  et  Troisier.  "  Note  sur  deux  caa  d'atrophie  musculaire  progressive." 
Arch,  de  physiologic,  1875. 


958 


SYSTEM  DISEASES   OF  THE 


the  right  anterior  grey  horn  {Fig.  202,  B),  however,  the  cells 
could  only  be  distinguished  in  one  group — the  postero-lateral 
{Fig.  202,  6) — while  the  cells  of  the  remaining  groups  were 
completely  destroyed.  It  has  appeared  to  me,  however,  that 
too  little  attention  has  hitherto  been  paid  to  the  condition  of  the 
central  grey  column.  In  the  annexed  diagram,  from  Charcot 
{Fig.  202),  the  central  column,  especially  the  left  one,  is  seen  to 
be  intersected  by  enlarged  vessels,  and  that  of  itself  affords 
some  evidence  that  this  column  was  not  free  from  disease  in  the 
section  from  which  the  drawing  was  taken.  It  seems  to  me, 
indeed,  that  the  morbid  process  begins  on  each  side  of  the 
^central  canal,  probably  in  the  tissues  immediately  adjoining 
the  central  artery,  and  that  it  extends  outwards  and  forwards 
as  well  as  upwards  and  downwards  from  this  point  as  a  centre. 
In  a  transverse  section  of  the  middle  of  the  cervical  enlargement 
in  my  possession,  from  an  advanced  case  of  progressive  muscular 
atrophy,  the  material  of  which  I  owe  to  the  kindness  of 
Dr.    Dreschfeld,    it    was    unmistakable  that  the   central  grey 


Fig.  2.02, 


Fig.  202  (Charcot).  Transverse  Section  of  the  Cervical  Region  of  the  Spinal  Cord, 
fi'om  a  case  of  progressive  muscular  atrophy. — A,  Left  anterior  grey  horn  ;_  the 
ganglion  cells  have  persisted,  but  are  much  altered  in  appearance.  B,  Right 
anterior  grey  horn,  almost  complete  atrophy  of  the  cells,  one  group  only  (b) 
having  persisted. 


SPINAL   CORD  AND  MEDULLA   OBLONGATA. 


959 


column  was  more  severely  diseased  than  any  other  portion  of 
the  section.  The  central  column  was  traversed  by  enlarged 
vessels,  and  almost  all  structure  was  obliterated,  while  the 
various  groups  of  ganglion  cells  in  the  anterior  horns  were  dis- 
tinctly recognisable.  The  cells  of  the  median  area  were,  indeed, 
completely  destroyed,  so  that  not  a  trace  of  them  could  be  seen, 
and  a  large  number  of  the  marginal  cells  of  the  other  groups 
were  also  destroyed,  so  that  the  groups  themselves  were  separated 
by  unusually  large  spaces  which  were  destitute  of  cells  (Fig.  203). 

Fig.  203. 


Fig.  203  (Young).  Transverse  Section  from  the  Middle  of  the  Cervical  Enlargement 
of  the  Spinal  Coi'd,  from  an  advanced  case  of  progressive  muscular  atrophy. — 
cc,  Central  canal ;  i,  Internal,  al,  Antero-lateral,  and^^.  Posterolateral  groups 
of  ganglion  cells. 

The  cells  of  the  centres  of  the  groups  were,  however,  distinctly 
recognisable,  although  all  of  them  were  observed  to  be  in  a 
state  of  pigmentary  atrophy  {Fig.  174,  8).  I  have  also  observed 
in  one  of  my  sections  a  streak  of  degeneration  to  pass  along  the 
posterior  branch  of  the  central  artery  {Fig.  134,  1")  into  the 
substance  of  the  posterior  grey  horns,  and  this  may  explain  why 
analgesia  of  patches  of  the  skin  is  frequently  associated  with 
progressive  muscular  atrophy.     In  the  accompanying  woodcut 


960 


SYSTEM  DISEASES  OF  THE 


{Fig.  204),  borrowed  from  Leyden's^  great  work  on  the  diseases 
of  the  spinal  cord,  it  may  also  be  distinctly  recognised  that  the 
diseased  portions  occupy  mainly  the  central  columns  of  the  cord, 
and  that  there  are  lateral  extensions  of  the  disease  towards  the 
anterior  grey  horns  and  between  the  groups  of  ganglion  cells. 

Fig.  204. 


Fig.  204  (from  Leyden).  Transverse  Section  of  the  Spinal  Cm'd  from  the  Middle  of 
the  Cervical  Enlargement,  showing  that  the  central  column  and  a  large  portion  of 
the  anterior  grey  horns  are  diseased, 

A  case  of  progressive  muscular  paralysis  has  been  described 
by  Erb  and  Schultze,^  in  which  the  erector  spinse  through- 
out their  entire  extent,  the  trapezius  on  both  sides,  the  muscles 
connected  with  the  shoulder  blades,  those  of  the  upper  arm, 
the  pectorals,  the  gluteal  muscles,  and  the  flexors  of  the  legs 
on  the  thighs  were  atrophied.  The  case,  indeed,  appears  to 
have  been,  so  far  as  the  distribution  of  the  paralysis  is  con- 
cerned, very  like  that  of  Charlotte  A ,  already  described.    The 

patient  died  from  an  attack  of  syncope,  but  without  any  trace  of 
bulbar  symptoms,  and  a  microscopical  examination  of  the  spinal 
cord  showed  that  the  most  pronounced  changes  were  found  in 
the  "  central  region  of  the  grey  substance."  It  is  also  mentioned 
that  in  the  lower  half  of  the  lumbar  and  cervical  enlargements 


'  Leyden.  Klinik  der  Euckenmarkskrankheiten.  Bd.  II.  2,  1874.  (Taf.  V., 
Fig.  2,  c.) 

*  Erb  and  Schultze.  "  Ein  Fall  von  progressiver  Muskelatrophie  mit  Erkran- 
kung  der  granen  Vordersaulen  des  Euckeninarks."  Arch.  f.  Psychiat.,  Bd.  IX., 
1879,  p.  369. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  961 

the  ganglion  cells  had  disappeared  from  the  median  (central) 
group.  The  cells  of  the  other  groups  were  degenerated.  The 
whole  microscopical  report  of  the  case,  indeed,  bears  out  the 
idea  that  the  disease  began  in  the  central  column,  and  extended 
forwards  into  the  anterior  horns. 

The  result,  however,  in  both  series  of  cases,  is  the  same,  the 
ganglion  cells  being  destroyed.  Progressive  destruction  of  the 
cells  seems  then  to  be  the  essential  feature  of  the  morbid 
anatomy  of  the  disease.  It  is  right  to  add  that  Romberg,^ 
Landry,^  Oppenheimer,*  Friedberg,*  Duchenne,^  Friedreich,^  Lich- 
theim,^  and  others  found  the  anterior  grey  horns  normal,  but  it  is 
probable  that,  in  the  earlier  observations  at  least,  the  changes  in 
the  ganglion  cells  had  been  overlooked.  The  posterior  columns, 
the  posterior  horns,  the  posterior  roots,  and  the  inter -vertebral 
ganglia  have  been  found  in  a  state  of  degeneration,  in  addition 
to  the  affection  of  the  anterior  horns. 

Schneevogt^  found  the  sympathetic  in  the  neck  diseased  in  a 
case  examined  by  him.  The  cervical  sympathetic  was  converted 
almost  into  a  fatty  cord,  in  which  the  nerve  fibres  were  pressed 
aside  by  fat  cells,  which  contained  beautiful  crystals.  The  cer- 
vical ganglia  were  almost  entirely  changed  into  fat  cells,  and 
the  thoracic  part  of  the  sympathetic  also  abounded  in  fat.  Two 
similar  observations  were  made  by  Jaccoud,  and  he  inferred 
from  the  appearances  present  that  the  disease  began  in  the  sym- 
pathetic and  spread  along  the  rami  communicantes  to  the  cord 
and  along  the  peripheral  nerves  to  the  muscles.  Changes  in  the 
sympathetic  have  been  found  by  Swarzenski^  and  by  Dumdnil;^' 
while  other  observers  as  Landry,  Frommann,  Hayem,  Charcot  and 
Joffroy,  and  Friedreich  have  found  the  sympathetic  healthy. 

'  Komberg.    Klinische  Ergebnisse.    Berl.,  18G4.     p.  58, 
"^  Landrji.     Gaz.  m^d,  de  Paris,    1853.     p.  261. 

'  Oppenheimer.  Ueber  progressive  fettige  Muskelentartung,  Heidelb. ,  1855, 
p,  12. 

*  Friedberg.  Pathologie  und  Therapie  der  Muskellahmung,  Weimar,  1858. 
p.  48, 

*  Duchenne,     De  I'felectrisation  localisee.     S^e  Edit,,  1872,  p,  529. 
« Friedreich.     Op.  cit.    (Fallen  IV.,  X.,  and  XVII.) 

"  Lichtheim.  "Progressive  Muskelatrophie  ohne  Erkrankung  der  Vorder- 
horner  des  Hiickenmarkes."    Arch.  f.  Psychiat.,  Bd.  VIII.,  1878,  p.  521. 

*  Schneevogt.    Wiener  med.  Presse.     1869.     p,  652. 

°  Swarzenski.  Die  progressive  Muskelatrophie.  Diss.  Berl,,  1867 ;  Abstr. 
Virchow's  Jahresb.,  Bd.  II.,  1867,  p.  290. 

'"Dum^nil.    Gaz.  h^bdom.    (Obs.  3.)    1867.    p.  453. 

VOL.  I.  JJJ 


962  SYSTEM  DISEASES  OF  THE 

The  peripheral  nerves  distributed  to  the  affected  muscles  have 
also  been  found  affected  by  Schneevogt,  Trousseau,  Virchow, 
Fried  berg,  Haj-em,  Charcot  and  Joffroy,  Bamberger,  Rosenthal, 
Friedreich,  and  others.  The  degenerations  were  sometimes 
limited  to  the  finer  intra-muscular  nerve  branches,  and  at  other 
times  they  existed  in  the  large  nerve  trunks  and  in  the  plexuses. 
The  changes  observed  were  hyperplasia  of  the  neurilemma, 
multiplication  of  nuclei,  and  fibrillary  thickening  of  the  sheath 
of  Schwann.  Friedreich  also  found  varicose  dilatation  of  the 
medullary  sheath  with  secondary  atrophy  of  the  nerve  fibres. 
In  some  few  cases  examination  of  the  peripheral  nerves  gave 
negative  results. 

§  428.  Morbid  Physiology. — Various  theories  have  from  time 
to  time  been  advanced  to  account  for  the  symptoms  of  progressive 
muscular  atrophy.  The  theory  of  Cruvielhier,  who  regarded 
atrophy  of  the  anterior  roots  as  the  essential  morbid  alteration,  as 
well  as  the  views  of  those  authors  who  believe  that  the  symptoms 
are  caused  by  disease  of  the  peripheral  nerves,  antero-lateral 
columns,  or  posterior  columns  of  the  cord,  is  definitely  abandoned 
by  all  pathologists  in  the  present  day.  The  theory  first  advanced 
by  Schneevogt,  and  afterwards  elaborated  by  Jaccoud,  which 
attributes  the  disease  to  a  morbid  change  of  the  sympathetic,  now 
reckons  only  few  adherents.  la  the  first  place,  the  sympathetic  is 
by  no  means  regularly  affected  in  progressive  muscular  atrophy  ; 
and  when  it  is  implicated  the  morbid  change  is  declared  by  the 
superadded  symptoms,  which  may  be  briefly  summed  up  as 
oculo-pupillary  phenomena.  In  short,  the  disease  of  the  sym- 
pathetic is  an  occasional  concomitant  affection ;  and  in  these 
cases  the  morbid  changes  appear  to  be  propagated  from  the 
anterior  horns  along  the  rami  communicantes  to  th6  cervical 
and  dorsal  portion  of  the  sympathetic  trunk  and  ganglia.  It  is 
not  impossible  that  a  reverse  process  may  take  place,  but  even 
in  that  case  the  disease  of  the  anterior  horns,  so  far  as  the 
nervous  system  is  concerned,  would  be  the  fundamental  lesion 
of  the  affection. 

These  theories  being  disposed  of,  two  only  remain — the 
myopathic  theory,  of  which  Friedreich  is  the  declared  champion, 
and  the  neuropathic  theory,  of  which  Charcot  may  be  mentioned 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  963 

as  the  most  prominent  advocate,  Aran  first  advanced  the  myo- 
pathic theory,  but  in  his  day  the  constant  changes  which  have 
since  been  found  in  the  nervous  apparatus  had  not  been  dis- 
covered. No  one  denies  the  reality  of  these  changes  at  present ; 
the  only  question  which  arises  is  whether  the  muscular  alteration 
precedes  the  morbid  changes  in  the  cord,  or  whether  the  former 
are  secondary  to  and  caused  by  the  latter.  Progressive  muscular 
atrophy,  according  to  Friedreich,  begins  as  a  primary  chronic 
myositis.  The  intra-muscular  nerves  are  secondarily  implicated, 
and  a  chronic  neuritis  ascends  along  the  course  of  the  nerve 
trunks  to  their  roots.  The  neuritis  may  then  extend  in  the  cord 
itself,  and  produce  a  chronic  myelitis,  which  may  spread  in 
various  directions,  the  ganglion  cells  of  the  anterior  horns  and 
the  efferent  fibres  which  connect  them  with  the  muscles  being 
specially  liable  to  be  affected.  Various  objections  may  be 
urged  against  this  theory,  not  the  least  important  of  these 
being  the  fact  that  the  peripheral  nerves  and  anterior  nerve 
roots  have  been  found  quite  normal  in  a  considerable  number 
of  cases. 

Friedreich  would  supplement  the  theory  of  neuritis  ascendens 
by  the  subordinate  theory  that  simple  suspension  of  muscular 
action  would  of  itself  cause  atrophy  of  the  ganglion  cells.  But 
the  changes  observed  in  the  anterior  horns  of  the  cord  in  the 
case  of  amputated  limbs  do  not  equal  in  severity  those  found 
in  progressive  muscular  atrophy.  This  theory  also  utterly  fails 
to  account  for  those  cases  in  which  the  destruction  of  the  grey 
matter  of  the  anterior  horns  is  produced  by  slow  compression 
from  gradual  distension  of  the  central  canal  by  fluid.  Various 
other  objections  might  be  urged  against  the  myopathic  theory, 
but  enough  has  been  said  to  show  that  it  at  least  presents  wide 
gaps  which  must  be  filled  up  before  it  can  be  considered 
established. 

The  neuropathic  theory  has  at  least  the  merit  of  being  simple, 
and  of  presenting  fewer  difficulties.  According  to  it,  the  atrophy 
is  due  to  the  progressive  changes,  primarily  of  an  irritative 
character,  of  the  ganglion  cells  of  the  anterior  horns.  Progressive 
bulbar  paralysis,  which  is  so  frequently  associated  with  pro- 
gressive muscular  atrophy,  is  an  analogous  affection  caused  by 
morbid  changes  in  the  groups  of  motor  cells  lying  in  the  floor 


964  SYSTEM  DISEASES   OF  THE 

of  the  fourth  ventricle,  the  reason  that  the  two  diseases  are  so 
frequently  associated  being  merely  that  the  morbid  process 
extends  from  the  anterior  horns  by  continuity  to  the  motor 
centres  in  the  floor  of  the  fourth  ventricle.  The  distinction 
between  the  two  diseases  is,  indeed,  dependent  upon  the  locality 
of  the  lesion  in  each  case.  In  both  tliese  diseases  the  nature  of 
the  lesion  which  destroys  the  ganglion  cells  is  of  little  import- 
ance. Much  the  same  results  (except  probably  in  respect  to  the 
rapidity  with  which  the  atrophy  is  developed)  follow  ordinary 
grey  degeneration,  chronic  induration,  myelitis,  red  softening, 
Clarke's  granular  degeneration,  or  isolated  pigmentary  degenera- 
tion of  the  ganglion  cells. 

On  the  supposition  that  the  disease  begins  in  the  central  grey 
column  and  extends  outwards  and  forwards  into  the  anterior 
grey  horns,  it  may  be  readily  explained  why  the  groups  of 
muscles  engaged  in  special  actions  are  usually  the  first  to  be 
affected.  We  have  already  seen  that  the  central  column  is  the 
embryonic  area  of  the  grey  substance,  and  that  the  median  area 
of  the  anterior  horns  in  the  lumbar  and  cervical  enlargements, 
and  the  medio-lateral  areas  in  the  dorsal  and  upper  cervical 
regions  of  the  cord,  may  be  regarded  as  outgrowths  of  the  central 
column.  The  median  and  medio-lateral  areas  will  consequently 
be  the  first  portions  of  the  anterior  horns  to  be  affected,  and  the 
portions  which  contain  the  fundamental  cells  will  be  the  last  to 
become  diseased.  When,  therefore,  the  lumbar  and  dorsal 
regions  of  the  cord  are  affected,  the  muscles  which  maintain  the 
erect  posture  in  man  will  be  those  most  liable  to  be  affected,  and 
the  patient's  gait  will  then  be  somewhat  similar  to  that  of  pseudo- 
hypertrophic paralysis.  Again,  when  the  cervical  enlargement  is 
the  first  to  be  affected,  the  morbid  process  will  extend  more  readily 
forwards  to  the  median  area  than  in  any  other  direction,  and  the 
small  muscles  of  the  hand,  and  especially  those  engaged  in  the 
most  special  actions,  such  as  the  opponens  pollicis,  will  be  first  to 
be  affected.  It  will  hereafter  be  pointed  out  that  when  the  medulla 
oblongata  is  first  affected  the  disease  begins  in  the  upward  con- 
tinuation of  the  central  column,  and  that  the  accessory  nuclei 
will  be  liable  to  become  first  diseased;  and  hence  it  is  that  the 
complicated  movements  of  articulation  are  generally  the  first  to 
iDecome  implicated. 


SPINAL  CORD  AND   MEDULLA   OBLONGATA.  965 

On  the  supposition  that  the  morbid  process  begins  in  the 
central  column,  it  may  also  be  readily  explained  why  muscles 
innervated  from  different  levels  of  the  cord  may  be  affected, 
while  muscles  innervated  from  the  intervening  portion  are 
spared,  without  our  being  obliged  to  assume  that  the  morbid 
process  in  the  cord  has  started  from  two  or  more  centres  of 
origin.  The  morbid  process  may,  for  instance,  extend  forwards 
into  the  median  area  in  the  cervical  enlargement,  while  it  may 
pass  upwards  through  the  upper  cervical  region  and  keep  limited 
to  the  immediate  neighbourhood  of  the  central  canal,  where  it 
would  produce  no  symptoms,  and  then  on  reaching  the  medulla 
oblongata  extend  to  the  accessory  nuclei,  and  thus  produce  the 
symptoms  of  bulbar  paralysis. 

§  429.  Diagnosis. — The  partial  form  of  the  disease  is  liable  to 
be  confounded  with  muscular  atrophy  caused  by  direct  mechanical 
injury  to  the  muscle,  or  with  the  various  diseases  of  the  peri- 
pheral nerves.  If  the  disease  remain  confined  to  the  muscles 
originally  affected,  or  to  the  region  of  a  single  nerve  trunk, 
progressive  muscular  atrophy  can  be  excluded.  The  muscular 
atrophy  which  results  from  disease  of  a  mixed  nerve  is  usually 
accompanied  by  loss  of  sensation. 

Progressive  muscular  atrophy  may  also  be  confounded  with 
lead  palsy ;  in  the  latter  the  invasion  is  comparatively  sudden, 
the  paralysis  being  at  its  height  in  a  week  or  a  fortnight  at  most, 
the  loss  of  muscular  power  is  in  excess  of  the  muscular  emaciation, 
and  the  electrical  contractility  is  diminished  or  lost  at  an  early 
period;  while  in  the  former  the  atrophy  precedes  the  paralysis, 
and  the  electrical  contractility  is  maintained  so  long  as  any 
muscle  is  preserved.  The  blue  line  on  the  gums  and  the  general 
symptoms  which  characterise  lead  poisoning  will  also  assist  the 
diagnosis. 

Chronic  atrophic  spinal  paralysis  may  be  distinguished  from 
progressive  muscular  atrophy  by  the  facts  that  in  the  former  the 
paralysis  precedes,  and  is  seldom  proportional  in  degree  to,  the 
muscular  emaciation;  the  "reaction  of  degeneration"  is  present 
in  the  muscles  at  an  early  period  in  the  course  of  the  disease, 
and  extensive  groups  of  muscles  are  more  or  less  simultaneously 
attacked.    In  progressive  muscular  atrophy  the  muscular  emacia- 


966  SYSTEM  DISEASES  OF  THE 

tion  precedes,  or  advances  in  a  proportionate  degree  with  the 
paralysis ;  the  "  reaction  of  degeneration,"  if  present  at  all,  in  the 
muscles,  is  only  met  with  at  a  late  period  of  the  disease,  and 
the  atrophy  attacks  the  muscles  in  separate  groups,  dissecting 
out  either  individual  muscles  or  groups  of  muscles  from  amongst 
others  which  remain  healthy. 

The  diagnosis  between  progressive  muscular  atrophy  and 
infantile  paralysis  has  been  mentioned  already. 

In  some  cases  the  first  paralytic  symptoms  in  progressive 
muscular  atrophy  are  ushered  in  by  epileptiform  attacks,^  each 
of  which  may  be  followed  by  a  comatose  condition  lasting  two 
or  three  days.  In  such  cases  the  paralysis  will  at  first  appear 
to  be  caused  by  a  cerebral  lesion,  and  it  may  be  impossible  to 
recognise  the  true  nature  of  the  disease  until  it  is  declared  by 
the  presence  of  a  progressive  atrophy  of  the  muscles.  The 
presence  of  gastric  crises  in  these  cases  may  for  some  time 
render  it  difiicult  to  distinguish  between  this  disease  and 
progressive  locomotor  ataxia,  but  the  appearance  of  muscular 
atrophy  and  the  continued  absence  of  all  the  other  symp- 
toms of  locomotor  ataxia  will  after  a  time  render  the  diagnosis 
clear. 

§  430.  Prognosis. — Progressive  muscular  atrophy  is  always 
very  intractable,  and  when  the  muscles  of  the  trunk  are  invaded 
it  always  progresses  slowly  towards  a  fatal  termination.  In  the 
partial  forms,  when  the  disease  is  limited  to  one  or  two  extremities, 
there  is  no  danger  to  life,  but  the  limbs  are,  as  a  rule,  permanently 
damaged.  In  many  cases  the  advance  of  the  disease  may  be 
checked,  and,  so  long  as  voluntary  motion  and  the  electrical 
reactions  are  not  completely  lost,  some  hope  may  be  entertained 
that  partial  restoration  of  the  affected  muscles  may  take  place. 
The  most  unfavourable  cases  are  those  which  begin  in  a  multiple 
form  and  spread  rapidly.  The  cases  in  which  the  disease  begins 
in  the  thorax  or  shoulder  are  unfavourable,  because  the  affection 
is  very  liable  to  implicate  the  respiratory  muscles.  When  bulbar 
symptoms  supervene  the  prognosis  is  specially  unfavourable,  and 

'  Joffroy  (A.).  "Observations  pour  servir  a  Thistoire  de  I'atrophie  musculaire, 
Acces  convulsifs  et  comateux.  Crises  gastriques."  Arch,  de  Neurologie,  Tome  II., 
1881,  p.  232, 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  967 

when  the  muscles  of  respiration  are  invaded  a  fatal  termination 
may  be  expected  within  a  short  time.  When  the  disease  can  be 
traced  back  to  a  hereditary  predisposition  it  manifests  a  greater 
tendency  to  become  generalised,  and  consequently  the  prognosis 
is  more  unfavourable.  The  prognosis,  on  the  other  hand,  is 
more  favourable  when  the  affection  is  caused  by  overwork  and 
when  it  is  confined  to  the  hands  and  forearms. 

§  431.  Treatment — An  attempt  must  first  be  made  to  remove 
the  cause.  When  the  disease,  for  instance,  is  caused  by  a  syphilitic 
taint  the  usual  antisyphilitic  treatment  must  be  adopted.  If 
overwork  of  the  affected  muscles  appear  to  have  been  the 
exciting  cause  of  the  disease,  they  must  be  allowed  to  rest. 
When  a  decided  hereditary  predisposition  to  the  affection  is 
manifested  in  a  family,  prophylactic  measures  may  be  employed, 
such  as  a  regulated  course  of  gymnastics ;  the  members  of  such 
families  should  also  be  shielded  from  deleterious  influences, 
especially  those  which  are  known  to  excite  the  disease. 

The  direct  treatment  of  the  established  disease  embraces  the 
employment  of  hygienic  measures,  such  as  baths,  methodical 
exercise,  change  of  air  and  good  diet,  and  the  employment  of 
galvanism  and  friction  to  the  affected  muscles.  No  medicine 
has  hitherto  been  found  of  any  use  in  the  treatment  of  this 
disease.  Tonics,  as  iron  and  quinine,  may  be  useful  adjuncts  in 
the  treatment,  and  the  nitrate  of  silver,  arsenic,  phosphorus,  and 
iodide  of  potassium  have  been  employed,  but  with  doubtful 
success. 

Thermal  and  sulphur  baths  have  been  recommended,  and  the 
waters  of  Aix-la-Chapelle  have  been  much  praised,  but  appa- 
rently on  insufficient  evidence.  The  cold  water  cure,  conducted 
in  a  good  hydropathic  establishment,  may  occasionally  be  found 
useful. 

Galvanism  is  undoubtedly  the  most  efficient  remedy  for  the 
disease.  The  local  use  of  the  faradic  current  was  applied  by 
Duchenne,  who  obtained  favourable  results  from  it,  but  the 
galvanic  is  probably  more  efficient  than  the  faradic  current. 
The  local  use  of  both  currents  alternately  has  given  good  results. 

When  the  muscular  excitability  is  very  low,  strong  currents  are 
required,  and  their  effects  should  be  intensified  by  interruptions 


968  SYSTEM  DISEASES   OF  THE 

and  reversals,  but  as  the  excitability  returns,  weaker  currents 
should  be  employed.  Suitable  gymnastics,  to  call  forth  the 
activity  of  the  affected  muscles,  passive  motion,  shampooing, 
and  friction,  are  all  useful  in  the  treatment  of  the  disease. 
When  the  muscular  atrophy  is  associated  with  neuralgia  the 
subcutaneous  iujection  of  morphia  may  be  employed.  Dr. 
Roberts  recommends  an  injection  to  be  given  in  the  morning, 
and  he  states  that  it  often  enables  the  patient  to  pursue  his 
employment  with  comfort  during  the  day. 

(6)  Primary  Labio-Glosso-Laryngeal  Paralysis. 

(Chronic  Progressive  Bulbar  Paralysis. — Wachsmuth.) 

§  432.  Definition. — Labio-glosso-laryngeal  paralysis  consists 
of  a  progressive  paralysis  and  atrophy  of  the  muscles  of  the 
tongue,  lips,  soft  palate,  pharynx,  and  larynx. 

§  433.  History. — A  brief  report  of  a  case  of  tMs  affection  was  sent  to 
Sir  Charles  BelP  in  1825  by  Dr.  E.  W.  Eobinson,  and  Trousseau^  wrote  an 
accurate  account  of  the  symptoms  in  1841,  but  did  not  publish  his  observa- 
tions. The  symptoms  of  the  affection  as  a  complication  of  progressive 
muscular  atrophy  were  observed  by  Dumenil^  in  1859,  but  it  was  not  recog- 
nised as  a  separate  disease  until  1861,  when  Duchenne*  described  it  with  his 
usual  exhaustiveness  and  thoroughness.  In  1864  Wachsmuth^  wrote  an  able 
monograph  on  the  disease,  and  named  it  progressive  bulbar  paralysis.  Since 
that  time  the  disease  has  been  studied  by  Wilks,®  Charcot,''  Schulz,^  Huber,^ 

'  Bell.  On  the  nervous  system  of  the  human  body.  Lond.,  1830.  Appendix 
(oaseLVII.),  CXVII. 

^  See  Trousseau.  Lectures  on  clinical  medicine.  New  Syd.  Soc,  Lond,,  1868, 
Vol.  I.,  p.  117. 

'  Dumenil.  "  Atrophic  des  nerfs  hypoglosses,  faciaux,  spinaux,  et  racines 
anterieures  des  nerfs  rahidiens,  &c."    Gaz.  hebdom.,  1859,  p.  390. 

"  Duchenne.  "  Paralysie  musculaire  progressive  de  la  langue,  du  voile  du  palais 
et  des  levres,"  Arch,  genc^r.  de  mdd.,  Vol.  II.,  1860,  pp.  283  and  431;  De  I'elec- 
trisation  localis^e,  3^6  Edit.,  1872,  p.  564. 

*  Wachsmuth.  XJeber  progressive  Bulbar -Paralyse,  und  Diplegia  facialis. 
Dorpat,  1864. 

"  Wilks.  "  Select  clinical  cases,  including  labio-glosso-laryngeal  paralysis,  &c." 
Guy's  Hospital  Reports,  Vol.  XV.,  1870,  p.  1 ;  and  Diseases  of  the  nervous  system, 
1878,  p.  253. 

'■  Charcot.  Arch,  de  physiologic,  Tome  II.,  1870,  p.  247  ;  et  Le9on8  sur  les 
maladies  du  systeme  nerveux,  Tome  II.,  '^^  Edit.,  1877,  pp.  239  et  425. 

*  Schulz  (R.).  "Beitrag  zur  die  Bewegungsstorungen  der  Zunge."  Wiener 
med.  Wochenschr.,  1864,  pp.  324,  613. 

^  Huber.  "Beitrag  zur  klinischen  Geschichte  der  Paralysis  Glosso-pharyngo- 
labialis."    Deutsches  Arch.  f.  klin.  Med.,  Bd.  II.,  1867,  p.  520. 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  969 

Leyden/  Friedreich,^  Clieadle,^  Benedikt,*  Clarke,^  Bourdon,^  Kussmaul,'' 
Maier,^  Habershon,^  Hammond,^"  Dowse/^  Kayser,^  Eobinson,^^  Fox," 
and  others. 

§  434.  Etiology. — It  does  not  appear  that  heredity  exercises 
any  influence  in  the  production  of  labio-glosso-iaryngeal  para- 
lysis. It  occurs  most  frequently  between  the  fortieth  and 
seventieth  years  of  age,  and  only  exceptionally  before  the 
fortieth  year.  The  disease  has,  however,  been  met  with  in 
young  people.  The  symptoms  were  observed  by  Kayser^^  in  a 
boy  of  twelve  years  of  age,  by  Frerichs^^  in  a  boy  of  ten,  by 
Wachsmuth  in  a  girl  of  seventeen,  and  by  Hitzig^^  in  a  girl  of 
six  years,  the  symptoms  in  the  last  case  dating  most  probably 
from  birth.  In  Kayser's  case  the  extremities,  which  were  par- 
tially paralysed,  manifested  lively  tremors  on  voluntary  move- 
ments of  the  limb,  these  being  especially  marked  in  the  right 
arm,  which  was  more  paralysed  than  the  left.     It  is  very  pro- 

'  Leyden.  "  Vorlaufige  Mittheilunsr  liber  progressive  Bulbarparalyse,"  Arch.  f. 
Psvchiat.,  Bd.  II.,  1870,  p.  423;  "  Ueber  progressive  Bulbitr-Paralyse,"  Ibid., 
Bd.  II.,  1870,  p.  643;  und  "Zur  progressiven  Bulbarparalyse,"  Ibid.,  Bd.  IV., 
1872,  p.  338. 

''  Friedreich.     Ueber  progressive  Muskelatrophie.     Eerl.,  1873.    p.  335. 

^  Cheadle.  "Labio-glosso-laryngeal  paralysis."  St.  George's  Hospital  Eeports, 
Vol.  v.,  1871,  p.  123. 

*  Benedikt.  "Zur  Casuistik  der  progressive  Labmuner  der  Gehimnerven." 
Deutsches  Arch.  f.  klin.  Med.,  Bd.  XI.,  1872,  p.  210;  Bd.  XIII.,  1874,  p.  94. 

*  Clarke  (Lockhart).  Progressive  muscular  atrophy.  Medico-Chir.  Transactions, 
Vol.  LVI.,  1873,  p.  103. 

°  Bourdon.  "Etude  sur  les  maladies  dii  bulbe  rachidien."  Gaz.  hebd.,  1872, 
p.  354. 

^  Kussmaul.  "Ueber  fortschreitende  Bulbarparalyse  und  ihr  Verhaltniss  zur 
progressiven  Muskelatrophie."  Volkmann's  Sammlung  klin.  Vortiage,  No.  20 
(Innere  Medicin),  p.  439. 

^  Maier  (R.).  "Fall  von  fortschreitender  Bulbarparalyse."  Virchow's  Arch., 
Bd.  LXL,  1874,  p.  1. 

°  Habershon.  "  Glosso-laryngeal  paralysis."  Guy's  Hospital  Reports,  Vol.  XX., 
1875,  p.  334. 

'°  Hammond.     The  diseases  of  the  nervous  system.     7th  Edit.,  1881,  p.  517- 

1'  Dowse.  "Bulbar  paralysis."  The  British  Medical  Journal,  Vol.  II.,  1876, 
pp.  580  and  614  ;  and  the  Lancet,  Vol.  I.,  1876,  p.  349. 

'*  Kayser.  "  Zur  Lehre  von  der  progressiven  Bulbarparalyse."  Deutsches  Arch, 
f.  klin.  Med,,  Bd.  XIX.,  1877,  p.  145. 

^^  Robinson.     "  Bulbar  paralysis."    The  Lancet,  Vol.  II.,  1878,  p.  543. 

'*  Fox  (A.  W.).  "  Case  of  progressive  muscular  atrophy  with  bulbar  paralysis." 
The  British  Medical  Journal,  Vol.  I.,  1881,  p.  82. 

'*  Kayser.  "  Zur  Lehre  von  der  progressiven  Bulbarparalyse."  Deutsches  Arch, 
f.  klin.  Med.,  Bd.  XIX.,  1877,  p.  145. 

'^  See  Wachsmuth.  "Ueber  progressive  Bulbar-Paralyse,  und  Diplegia  facialis." 
Dorpat,  1864. 

' '  Hitzig.    Berl.  klin.  Wochenschrif t.    1874.    p.  465. 


970  SYSTEM  DISEASES  OF  THE 

bable,  therefore,  that  this  case  was  really  an  example  of  sclerosis 
in  patches,  in  which  the  lesion  had  begun  at  an  early  period  in 
the  bulbar  nuclei.  KussmauP  remarks  that  the  cases  described 
by  Frerichs  and  Wachsmuth  depart  in  so  many  respects  from  the 
typical  course  of  primary  progressive  labio-glosso-laryngeal 
paralysis  that  it  is  very  doubtful  whether  they  ought  to  be 
included  in  this  category.  A  critical  analysis  of  these  cases, 
therefore,  shows  Duchenne's^  statement,  that  this  form  of  paralysis 
is  a  disease  of  adult  age,  to  be  still  correct.  The  disease  attacks 
men  more  frequently  than  women,  the  proportion  being  two 
of  the  former  to  one  of  the  latter.  All  ranks  of  society  from 
the  highest  to  the  lowest,  and  every  profession,  appear  to  be 
liable  to  the  affection. 

Of  the  exciting  causes,  the  most  frequently  mentioned  are 
exposure  to  cold,  traumatic  influences,  as  a  blow  on  the  back  of 
the  neck,  violent  and  continuous  mental  excitement,  excessive 
mental  activity,  straining  of  the  muscles  affected,  as  in  singing 
and  speaking,  and  bad  and  insufficient  food.  Syphilis  is  not  an 
unfrequent  cause  of  the  disease;  but  the  authors  who  regard 
this  affection  as  being  almost  always  of  syphilitic  origin  are  un- 
doubtedly in  error. 

§  485.  Symptoms. — Slight  premonitory  symptoms  usually 
precede  the  full  development  of  the  disease,  but  they  are  often 
entirely  wanting  and  are  not  in  any  way  characteristic  of  the 
affection.  These  consist  of  pain  in  the  head  and  back  of  the 
neck,  slight  dizziness,  and  great  diminution  or  complete  loss 
of  the  reflex  irritability  of  the  larynx,  oesophagus,  and  pharynx.^ 
The  reflex  insensibility  of  the  mucous  membrane  of  the  fauces, 
epiglottis,  and  pharynx  is  sometimes  so  great  as  to  lead  to  a 
certain  amount  of  dysphagia,  and  the  passage  of  food  into  the 
larynx  for  a  considerable  time  before  any  actual  paralysis  is 
observed.  In  a  case  in  which  the  paralytic  symptoms  were 
moderately  advanced,  kindly  sent  to  me  for  examination  a  few 

1  Kussmaul.  Volkmann's  Sammlung  klin.  Vortrage,  No.  20  (Innere  Medicin). 
p.  448. 

■■'  Duchenne.     De  I'electrisation  localises .    3™e  Edit.,  1872,  p.  1857. 

^  Krisliaber.  "  L'ansesth^sie  de  la  sensibility  r^flexe  dese  voies  aerienne  et  digestif 
comrae  signe  pr^curseur  de  la  paralysie  labio-glosso-laryng^e."  Gaz.  hebdom.,  1872, 
p.  772. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  971 

weeks  ago  by  my  friend  Dr.  Hodgkinson,  there  was  considerable 
hyperaestbesia  of  the  mucous  membrane  of  the  palate  and 
pharynx,  and  the  slightest  touch  of  the  back  of  the  throat  called 
forth  exaggerated  reflex  actions. 

The  disease  may  begin  suddenly  with  difficulty  in  the  move- 
ments of  the  tongue  and  lips,  and  of  deglutition ;  but  in  these 
cases  it  is  probable  that  a  slight  hsemorrhage  has  occurred  in 
the  medulla,  and  consequently  they  cannot  be  regarded  as  true 
instances  of  the  primary  disease. 

The  symptoms  of  the  true  progressive  disease  creep  on 
gradually  and  stealthily.  A  slight  affection  of  speech  is  usually 
the  first  symptom  to  attract  attention ;  articulation  is  less  dis- 
tinct, the  pronunciation  of  certain  letters  presents  special 
difficulty,  and  the  tongue  and  lips  are  soon  fatigued,  so  that 
prolonged  reading  aloud  or  speaking  is  impossible. 

This  is  followed  by  a  gradual  weakness  in  the  lips  and  palate. 
The  expression  of  the  face  is  altered,  the  voice  becomes  nasal, 
and  fatigue  of  the  muscles  of  mastication  and  deglutition  is 
readily  induced,  so  that  the  patient  is  soon  compelled  to  eat 
only  pulpy  food,  and  is  unable  to  swallow  much  at  one  meal. 

The  paralytic  symptoms  may  at  times  begin  in  the  lips  and 
palate  instead  of  the  tongue,  and  then  the  order  of  succession 
of  the  symptoms  will  differ  to  some  extent  from  that  just 
described. 

The  initial  period  of  debility  and  fatigue  of  the  affected 
muscles  may  extend  over  a  period  of  years  before  the  stage  of 
distinct  paralysis  is  reached.  When  once  distinct  paralysis  is 
established,  the  disease  assumes  a  more  progressive  character, 
and  advances  steadily  and  surely  to  a  fatal  termination. 

When  the  affection  begins  in  the  tongue,  the  patient  expe- 
riences an  ever-increasing  difficulty  in  pronouncing  the  dental 
and  guttural  sounds  which  are  respectively  produced  by  approxi- 
mation of  the  tongue  to  the  teeth  or  hard  palate,  and  of  the  root 
of  the  organ  to  the  soft  palate.  Since  the  vowel  i  requires  the 
greatest  raising  of  the  tongue  for  its  production,  its  pronuncia- 
tion is  the  first  to  suffer ;  and  then  the  pronunciation  of  the 
consonants  r,  s,  1,  k,  g,  t,  and  lastly  d  and  n,  becomes  difficult, 
imperfect,  and  finally  impossible. 

After  a  time  the  patient  is  unable  to  effect  the  coarser  and 


972  SYSTEM  DISEASES  OF  THE 

least  complicated  lingual  movements.  He  may  at  first  be  able 
to  protrude  the  tongue,  but  not  to  raise  the  tip  towards  the  hard 
palate  or  towards  the  nose  after  protrusion;  while  inability  to 
move  the  tip  laterally  indicates  a  still  greater  degree  of  paralysis. 
As  the  paralysis  increases  the  tongue  cannot  be  lengthened  into 
a  point,  or  made  hollow  in  the  centre;  and,  finally,  protrusion  is 
impossible,  and  the  organ  lies  behind  the  lower  row  of  teeth 
completely  helpless  and  motionless,  or  maintained  in  constant 
vibration  with  fibrillary  twitchings. 

The  tongue  may  maintain  its  normal  aspect,  or  become  large 
and  flabby;  but  much  more  frequently  it  is  sodden,  grooved 
longitudinally,  wrinkled,  and  shrunken,  while  simultaneous 
atrophy  of  the  papillae  gives  to  the  surface  a  glazed  appearance. 

At  an  early  stage  of  the  affection  deglutition  is  rendered 
difficult,  simply  by  the  increasing  weakness  of  the  tongue. 
Great  difficulty  is  experienced  in  collecting  the  food  in  the 
mouth  so  as  to  form  it  into  a  bolus,  and  in  pressing  it  back 
against  the  soft  palate  and  into  the  pharynx;  and  the  patient 
adopts  various  devices  in  order  to  supplement  the  deficiencies 
of  the  first  stage  of  deglutition.  He  takes  care,  as  Trousseau 
remarks,  to  chew  well  what  he  eats,  and  to  facilitate  its  gliding 
down  by  drinking  and  throwing  his  head  backwards,  while  at 
other  times  he  assists  the  imperfect  movements  of  the  tongue 
with  his  fingers,  using  them  to  extract  the  food  which  has. 
lodged  between  the  teeth  and  cheeks,  and  to  push  the  bolus  to 
the  back  of  the  tongue  till  it  is  caught  by  the  reflex  movements 
of  deglutition. 

The  muscles  which  pass  from  the  inferior  maxilla  to  the  hyoid 
bone,  and  which  elevate  the  larynx  as  well  as  the  base  of  the 
tongue  during  deglutition,  are  implicated  in  the  paralysis  along 
with  the  intrinsic  muscles  of  the  tongue;  hence  it  may  be 
observed  that  the  larynx  does  not  rise  so  readily  as  in  health 
during  the  second  stage  of  deglutition.  The  root  of  the  tongue 
cannot,  therefore,  be  brought  during  deglutition  over  the  de- 
pressed epiglottis,  the  glottis  is  not  completely  closed,  particles 
of  food  and  fluids  easily  find  their  way  into  the  trachsea,  and  cause 
distressing  paroxysms  of  cough  and  dyspnoea. 

The  saliva  cannot  be  swallowed  and  accumulates  in  the  mouth, 
and  owing  to  the  advancing  paralysis  of  the  orbicularis  oris  flows 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  973 

from  it  in  an  almost  continuous  stream.  Of  the  muscles  inner- 
vated by  the  facial  nerve  the  orbicularis  oris  is  the  first  to  suffer. 
With  the  increasing  weakness  of  this  muscle  the  patient  becomes 
unable  to  whistle,  blow,  compress  his  lips,  or  kiss.  The  patient 
experiences  difficulty  in  pronouncing  the  vowels  o  and  u;  and 
with  the  advance  of  the  paralysis  the  labial  consonants  p,  f,  b, 
and  m,  become  increasingly  difficult  to  articulate. 

Paralysis  of  the  palate  renders  the  formation  of  the  explosive 
labial  consonants  still  more  difficult;  since  the  current  of  air 
necessary  to  force  the  lips  suddenly  asunder  escapes  through 
the  nose,  and  the  consonants  p  and  b  are  consequently  turned 
into  me  and  ve.  Duchenne  has  shown  that  if  the  patient's  nose 
be  closed  these  letters  are  much  better  pronounced.  Paralysis 
of  the  palate  also  gives  a  nasal  resonance  to  the  voice,  and  per- 
mits food  and  fluids  to  escape  readily  through  the  nose  during 
efforts  at  deglutition.  "When  the  muscles  of  the  tongue,  lips, 
and  palate  are  simultaneously  paralysed,  speech  becomes  more 
and  more  indistinct,  and  the  patient  can  only  give  utterance  to 
inarticulate  and  grunting  sounds.  The  vowel  a,  however,  can 
still  be  pronounced,  inasmuch  as  it  is  a  purely  laryngeal  sound, 
and  quite  independent  of  the  articulatory  movements  of  the 
tongue  and  lips. 

But  although  the  orbicularis  oris  suffers  more  profoundly  than 
the  other  facial  muscles,  the  quadratus  and  levator  menti  are 
more  or  less  implicated  in  the  paralysis.  The  muscles  of  the 
palpebral  and  nasal  regions  are  never  affected,  and  even  the 
elevators  of  the  superior  lip,  as  well  as  the  levator  menti  and 
buccinators,  are  only  on  rare  occasions  involved  in  the  paralysis. 
The  paralysed  muscles  are  almost  always  distinctly  atrophied,  so 
that  the  lips  look  thin,  sharp  edged,  and  furrowed,  aad  fibrillary 
contractions  are  not  unfrequently  observed  in  them.  The  patient 
now  presents  a  very  striking  and  characteristic  appearance.  The 
lower  lip  hangs  loose  and  pendulous,  the  mouth  cannot  be  closed, 
it  is  somewhat  increased  in  breadth,  and  the  naso-labial  folds 
become  marked,  and  give  to  the  patient  a  lachrymose  expression. 
During  states  of  emotional  excitement  the  lower  part  of  the  face 
remains  comparatively  motionless,  and  contrasts  strongly  with 
the  vivacious  movements  of  the  upper  half  of  the  face,  and  with 
the  brightness  and  activity  of  the  eyes. 


974  SYSTEM  DISEASES   OF  THE 

The  saliva  now  flows  from  the  mouth  in  a  continuous  stream, 
and  causes  much  annoyance  to  the  patient,  inasmuch  as  it  soaks 
through  the  pillow  at  night  and  requires  to  be  constantly  wiped 
from  the  lips  with  a  handkerchief  during  the  day.  The  saliva 
appears  to  be  secreted,  as  a  rule,  in  normal  quantity,  but  in 
some  cases  the  amount  of  secretion  is  very  largely  increased. 
Schulz^  estimated  in  one  case  that  the  secretion  was  six  or  eight 
times  the  normal  amount,  and  Kayser^  found  that  he  could 
increase  the  flow  by  reflex  irritation,  and  arrest  it  temporarily 
by  means  of  atropine. 

Mastication,  as  already  mentioned,  is  impaired  at  an  early 
stage  of  the  affection  from  the  difficulty  of  moving  the  tongue, 
and  the  condition  becomes  aggravated  when  the  lips  and  buc- 
cinators are  simultaneously  paralysed.  But  the  difliculty  of 
mastication  is  greatly  augmented  when  the  motor  division  of 
the  trigeminus  is  involved  in  the  disease.  The  pterygoid 
muscles  are  usually  the  first  of  the  masticatory  muscles  to  be 
affected,  and  paralysis  of  them  abolishes  the  power  of  effecting 
the  lateral  movements  of  the  lower  jaw.  With  the  advancing 
paralysis  of  the  remaining  muscles  of  mastication,  the  power  of 
chewing  the  food  becomes  increasingly  difficult,  feeble,  and 
finally  impossible. 

The  difficulty  of  deglutition,  caused  by  paralysis  of  the 
tongue,  lips,  and  soft  palate,  is  greatly  augmented  when  the 
pharyngeal  muscles  and  those  which  close  the  larynx  are  in- 
volved in  the  disease.  When  the  pharyngeal  muscles  are 
paralysed  particles  of  food  are  apt  to  lodge  in  the  pharynx,  and 
this  increases  the  risk  of  foreign  particles  entering  the  larynx. 
At  other  times  the  whole  bolus  gets  fast  on  a  level  with  the 
glottis,  causing  danger  of  instant  suffocation. 

But  when  the  muscles  which  close  the  glottis  are  paralysed, 
the  danger  of  swallowing  either  solids  or  fluids  becomes  greatly 
intensified.  Particles  of  food  passing  into  the  larynx  produce 
distressing  paroxysms  of  coughing  and  dyspnoea,  and  by  passing 
into  the  bronchi  often  cause  pneumonia.  When  the  paralysis 
extends  to  the  oesophagus  deglutition  becomes  impossible,  and 
to  survive  the  patient  must  be  fed  by  the  stomach  pump.   When 

'  Schulz.     Wiener  med.  Wochenschrift.    1864.    Nos.  38  and  89. 
"  Kayser.    Deutsches  Arch.  f.  klin.  Med.    Bd.  XIX.,  1877,  p.  450. 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  975 

the  nucleus  of  the  spinal  accessory  nerve  is  involved  in  the 
disease  the  laryngoscope  reveals  paresis  or  paralysis  of  the  vocal 
cords,  the  voice  becomes  hoarse  and  feeble,  until  finally  there  is 
complete  aphonia.^  The  power,  not  of  articulation  only,  but  of 
phonation  also,  is  now  abolished,  the  loss  of  this  function  being 
manifested  by  inability  to  pronounce  the  vowel  a.  The  loss 
of  phonation  does  not  necessarily  interfere  with  the  respiratory 
functions,  but  as  the  disease  advances  disorders  of  respiration 
and  circulation  supervene,  which  soon  prove  fatal. 

Not  much  is  known  with  respect  to  disorders  of  the  circula- 
tion in  the  early  stages  of  the  affection.  There  is  no  trustworthy 
record  of  retardation  of  the  pulse  which  could  with  probability 
be  referred  to  irritation  of  the  vagus,  but  a  pulse  rising  before 
death  from  130  to  150,  or  even  higher  per  minute,  has  been 
frequently  recorded,  and  is  probably  caused  by  paralysis  of  the 
vagus.  In  the  terminal  period  of  the  disease  patients  often  suffer 
from  fainting  fits,  accompanied  by  great  anxiety  and  a  sensation 
of  impending  death,  and,  indeed,  death  may  result  from  an 
attack  of  syncope.  These  phenomena  are  probably  caused  by 
the  cardiac  centres  of  innervation  having  become  involved  in 
the  disease. 

When  the  respiratory  mechanism  is  affected  a  fatal  termi- 
nation is  near.  The  respiratory  movements  become  feeble,  and, 
owing  to  the  implication  of  the  spinal  accessory  nerves,  the 
auxiliary  muscles  of  respiration  are  paralysed,  and  superior 
thoracic  breathing  is  impossible.  The  inefficiency  of  the  respi- 
ratory movements  renders  the  breathing  shallow,  and  all  attempts 
at  coughing  or  blowing  the  nose  are  weak  and  powerless. 
Patients  complain  of  a  feeling  of  constriction,  accompanied  by  an 
oppressive  feeling  of  want  of  breath.  After  a  time  the  pneumo- 
gastric  nerve  appears  to  become  implicated  in  the  disease. 
Paroxysms  of  dyspnoea,  with  a  tendency  to  syncope,  supervene, 
but  these  must  not  be  confounded  with  the  suffocative  attacks 
which  occur  at  an  early  period  from  the  accidental  introduction 
of  foreign  bodies  into  the  larynx.  The  attacks  of  dyspnoea 
become  more  and  more  frequent  as  the  disease  progresses,  and 
the  breathing  power  feebler  and  feebler,  until  ultimately  the 

»  Trousseau.  Lectures  on  Clinical  Medicine.  New  Syd.  Soc,  1868,  Vol.  I., 
p.  131. 


976  SYSTEM  DISEASES  OF  THE 

patient  dies  from  asphyxia.  Death  may,  indeed,  be  caused  at  an 
early  period  of  the  affection  by  a  slight  disease  of  the  respiratory 
organs,  such  as  a  bronchial  catarrh  or  pneumonia. 

Atrophy  of  the  paralysed  muscles  is  one  of  the  most  constant 
and  striking  symptoms  of  this  affection.  It  is  usually  most 
marked  in  the  tongue,  and  the  lips  also  become  emaciated  and 
thin,  and  both  are  often  kept  in  constant  movement  by  fibrillary 
contractions.  Atrophy  of  the  soft  palate  has  not  yet  been 
recorded,  and  cannot  probably  be  recognised  with  certainty. 

Atrophy  of  the  paralysed  muscles  is  not  an  early  symptom  of 
the  disease,  and  does  not  run  a  parallel  course  with  the  paralysis. 
The  tongue,  may,  however,  retain  a  normal  appearance  and 
volume,  and  yet  exhibit,  on  microscopical  examination,  extensive 
degeneration  of  its  muscular  fibres.^ 

Local  atrophy  and  fibrillary  contractions  of  the  small  muscles 
of  the  hand  are  sometimes  observed  indicating  a  complication 
with  progressive  muscular  atrophy. 

The  electric  excitability  is  generally  said  not  to  undergo  any 
noteworthy  changes,  but  Erb  states  that  he  found  the  most 
marked  "reaction  of  degeneration"  on  direct  irritation  of  the 
muscles  of  the  chin,  lips,  and  tongue.  The  electric  irritability 
of  the  nerves  was,  however,  normal,  or  but  slightly  diminished. 

The  sensibility  remains,  as  a  rule,  unaffected  throughout  the 
whole  course  of  the  disease,  and  even  taste  is  only  altered  on  rare 
occasions.  Affections  of  the  auditory  nerve,  consisting  of  buzzing 
of  the  ears  and  deafness,  have  occasionally  been  observed.  The 
trigeminus  is  sometimes  implicated,  the  symptoms  observed 
being  a  furry  feeling  and  anaesthesia  on  both  sides  of  the  face, 
and  want  of  common  sensation  in  the  tongue,  and  in  some  cases 
pain  has  been  felt  in  the  occipital  and  upper  part  of  the  cervical 
region. 

TM  intelligence  remains  quite  clear  to  the  last,  the  temper 
is  somewhat  excitable,  and  patients  often  manifest  an  inclination 
to  laugh  or  weep  on  slight  provocation. 

Reflex  irritability  is,  as  already  mentioned,  sometimes  greatly 
diminished  or  abolished  in  the  tongue,  soft  palate,  pharynx,  and 
even  in  the  larynx  before  the  appearance  of  any  other  symptoms, 

'  Charcot.  Le9ons  sur  lea  maladies  du  systeme  nerveux.  Tome  II.,  2™«  Aufl  , 
1877,  p.  226. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  977 

but  on  the  other  hand  it  is  often  retained  in  these  parts  until 
a  late  period  of  the  disease.  Even  when  the  reflex  irritability 
is  lost  the  patient  can  feel  and  localise  each  touch  quite  dis- 
tinctly. 

Vaso-motor  disturbances  have  not  been  recorded,  and  there  is 
no  fever  during  the  whole  course  of  the  disease. 

General  nutritive  disorders  occur  sooner  or  later  in  the 
course  of  the  affection.  These  are  in  large  part  due  to  the 
insufficient  quantity  of  food  taken,  and  which  ultimately  pro- 
duces a  state  of  inanition.  The  helplessness  of  the  patient  is 
greatly  aggravated  by  his  inability  to  close  the  glottis,  and 
thus  all  forcible  expiratory  actions  are  rendered  impossible. 
Duchenne^  thought,  probably  on  sufficient  grounds,  that  the 
constant  loss  of  the  saliva  exercised  a  deleterious  influence  on 
digestion,  and  consequently  contributed  to  produce  the  general 
debility.  But  whatever  may  be  the  causes  which  co-operate  to 
produce  the  state  of  emaciation  and  marasmus  into  which  the 
patient  falls,  the  debility  at  last  becomes  so  great  that  he  is 
unable  to  get  up.  He  sits  in  bed,  with  the  upper  part  of  the 
body  propped  up,  and  with  the  head  resting  on  pillows  and 
inclined  to  one  side,  in  order  to  let  the  saliva  flow  out  of  the 
mouth,  and  death  soon  supervenes,  either  during  a  paroxysm  of 
dyspnoea  or  suddenly  and  quietly  from  arrest  of  the  heart's 
action. 

§  436.  Course,  Duration,  and  Terminations. — The  course  of 
bulbar  paralysis  is  always  slow  and  chronic,  but  surely  progressive. 
There  is  seldom  a  remission  of  long  duration  ;  any  degree  of 
improvement  is  still  rarer,  and  recovery  has  never  been  observed 
when  the  diagnosis  of  a  primary  affection  was  beyond  question. 
Death  usually  results  in  from  one  to  five  years. 

§  437.  Complications. — Progressive  muscular  atrophy  is  the 
most  important  and  frequent  complication  of  bulbar  paralysis. 
Labio-glosso-laryngeal  paralysis  may  either  be  the  primary  affec- 
tion, or  it  may  merely  be  a  terminal  phenomenon  surpervening 
in  the  course  of  progressive  muscular  atrophy,  and  caused  by 

'  Duchenne.    De  I'electrisation  localis^e.    8™*  Aufl.,  1872,  p.  575, 
VOL.  I.  KKK 


978  SYSTEM  DISEASES  OF  THE 

extension  of  the  morbid  process  in  the  anterior  grey  horns  of 
the  cord  to  the  motor  nuclei  of  the  medulla.  The  two  affec- 
tions are  indeed  essentially  the  same  disease,  both  as  regards 
the  clinical  symptoms  and  the  anatomical  changes  found  after 
death. 

Amyotrophic  lateral  sclerosis  is  another  important  com- 
plication of  progressive  bulbar  paralysis,  and  the  latter  may 
either  be  the  primary  or  secondary  affection.  Amyotrophic 
lateral  sclerosis  occurs  not  unfrequently  in  the  later  stages  of 
bulbar  paralysis.  The  disease  is  then  characterised  by  the 
symptoms  of  progressive  muscular  atrophy  in  the  superior  and 
those  of  spastic  spinal  paralysis  in  the  inferior  extremities.  A 
number  of  cases  described  as  bulbar  paralysis  or  progressive 
muscular  atrophy  belong  to  this  class.  The  disease  is  no  doubt 
due  to  extension  of  the  morbid  process  in  the  medulla  to  the 
anterior  grey  horns  of  the  cervical  enlargement  and  to  the 
antero-lateral  columns  of  the  cord. 

§  438.  Morbid  Anatomy. — The  first  observations  with  respect 
to  the  morbid  alterations  of  the  nervous  system  were  conducted 
without  careful  microscopical  examination  of  the  medulla  and 
pons.  In  a  complex  case  of  paralysis  of  the  tongue,  lips,  and 
veil  of  the  palate,  combined  with  general  muscular  atrophy, 
recorded  by  Dr.  Damenil,^  the  roots  of  the  hypoglossal,  facial, 
and  spinal  accessory  nerves,  as  well  as  the  anterior  spinal  roots, 
were  found  wasted,  the  atrophy  also  extending  to  the  trunks 
of  the  nerves  themselves.  Trousseau^  found  increased  con- 
sistency of  the  medulla  oblongata  and  thickening  of  the  dura 
mater  of  the  medulla ;  but  he  regarded  the  atrophy  of  the  roots 
of  the  bulbar  nerves  as  the  essential  morbid  alteration  in  this 
disease. 

The  close  anatomical  connection  which  the  researches  of 
Lockhart  Clarke  and  others  have  proved  to  exist  between  the 
nuclei  of  origin  of  the  nerves  implicated  in  this  disease,  as  well 
as  the  discovery  which  had  already  been  made  that  the  allied 

'  Dum^niL  "  Atrophic  des  nerfs  hypoglosses,  faciaux,  spinaux,  &c."  Gaz. 
hebdom.,  1859,  p.  390;  et,  "Noveaux  faits  relatifs  a  la  pathog^nie  de  I'atrophie 
musculaire  graisseuse  progressive,"  Gaz.  hebdom.,  1867,  p.  423. 

"Trousseau.  Lectures  on  Clinical  Medicine.  New  Syd.  See,  Vol.  I.,  1868, 
p.  121.    See  also  Wilks  and  Moxon.    Guy's  Hospital  Keports.    VoL  XV,,  1870,  p.  8. 


SPINAL   COED   AND  MEDULLA  OBLONGATA.  979 

affections  of  progressive  muscular  atrophy  and  infantile  spinal 
paralysis  were  due  to  disease  of  the  ganglion  cells  of  the  anterior 
grey  horns  of  the  cord,  had  led  pathologists  to  suspect  that  the 
essential  anatomical  changes  in  this  disease  would  be  found,  not 
in  the  roots  of  the  nerves,  but  in  the  ganglion  cells  of  their 
nuclei  of  origin.  It  was  in  reference  to  this  expectation  that 
Dr.  Wilks*  wrote :  "  The  anatomist  and  the  physiologist  have 
in  fact  informed  the  clinical  physician  of  the  precise  spot 
which  is  affected,  and  it  only  remains  for  the  pathologist  to 
prove  it." 

About  the  time  that  this  sentence  was  being  uttered  by  Dr. 
Wilks  the  opportunity  for  making  the  necessary  verification  of 
the  hypothesis  presented  itself  to  the  ever-vigilant  eye  of  Charcot,^ 
and  his  observation  was  soon  afterwards  confirmed  by  Duchenne 
and  Joffroy.^  The  essential  anatomical  changes  in  the  affection 
appear  to  consist  of  a  degenerative  atrophy  of  the  ganglion  cells 
in  the  grey  nuclei  on  the  floor  of  the  fourth  ventricle.  The  cells 
shrink  and  become  filled  with  yellow  or  brown  pigment,  their 
nuclei  disappear,  and  finally  the  cells  themselves  are  only  repre- 
sented by  angular,  glistening  pigmented  masses. 

In  some  cases  the  surrounding  tissue  was  found  to  contain 
corpuscles  of  Gluge  in  varying  quantity,  increase  of  connective 
tissue  and  in  the  number  of  nuclei  and  of  Deiter's  cells,  and 
hypertrophy  and  fatty  degeneration  of  the  vascular  walls.  The 
nerve  fibres  themselves  were  found  atrophied,  the  medullary 
sheath  had  disappeared,  and  in  chronic  cases  the  axis  cylinders 
also. 

The  nucleus  of  the  hypoglossal  nerve  appears  to  be  the 
starting  point  of  the  disease,  and  the  nuclei  of  the  spinal  acces- 
sory and  vagus  are  next  attacked,  while  the  disease  does  not 
extend  in  all  cases  to  the  nucleus  of  the  glosso-pharyngeal 
nerve.  The  nuclei  of  the  facial  are  attacked  at  a  very  early 
stage,  especially  those  which  are  connected  with  the  inferior 
branches  of  the  nerve,  and  which  I  have  named  the  accessory 

»  Wilks.    Guy's  Hospital  Reports.    VoL  XV.,  1870,  p.  2. 

"^  Charcot.  "  Note  sur  un  cas  de  paralysis  glosso-laryngee,  suive  d'autopsie." 
Arch,  de  physiologic,  Tome  III.,  1870,  p.  247. 

*  Duchenne  et  Jofifroy.  "  De  I'atrophie  aigue  et  chroniques  des  cellules  nerveuse 
de  la  moelle  epiniere  et  du  bulbe  rachidienne  apropos  d'une  observation  de  paralysie 
glosso-labio-laryngee."    Arch,  de  physiologie.  Tome  III.,  1870,  p.  499. 


980 


SYSTEM  DISEASES   OF  THE 


nuclei  of  the  facial.  The  annexed  diagram  {Fig.  205),  borrowed 
from  Leyden,^  represents  the  morbid  changes  observed  in  the 
medulla  oblongata  in  bulbar  paralysis.  Kemnants  of  the  fun- 
damental cells  of  the  hypoglossal  nuclei  may  still  be  observed, 
while  every  trace  of  the  accessory  nuclei  has  disappeared.  That 
the  upward  continuation  of  the  central  grey  column  at  the 
inferior  part  of  the  floor  of  the  fourth  ventricle  is  liable  to 
be  implicated  in  the  lesion  is  shown  by  a  case  of  progressive 
muscular  atrophy,  complicated  by  bulbar  paralysis,  reported  by 
Dr.  Fox.^  The  morbid  appearances  observed  were  those  of 
"myelitis  affecting  the  grey  matter,  more  particularly  that  of 
the  anterior  cornua,  most  marked  at  the  upper  dorsal  region,  but 
extending  upwards  around  the  central  canal  into  the  medulla, 
and  terminating  below  the  calamus  scriptorius." 

The  motor  nucleus  of  the  trigeminus  has  been  found  affected, 
but  the  nucleus  of  the  abducens  and  the  acoustic  and  trigeminal 
sensory  nuclei  appear  never  to  suffer.     Other  changes  have  been 

Fig.  205. 


NH- 


Fig.  205  [from  Leyden).  Portion  of  the  Grey  Substance  on  the  floor  of  the  fourth 
ventricle  on  a'level  loith  the  middle  of  the  Hypoglossal  Nucleus,  from  a  case  of 
Progressive  Muscular  Atrophy  with  Bulbar  Paralysis,  showing  the  destruction  of 
the  Ganglion  Cells  of  the  nuclei  of  the  Hypoglossal  and  Pneumogastric  Nerves  (NHj. 
a,  Median  raphe ;  H,  H,  Fibres  of  the  hypoglossal  nerves.  The  accessory 
nuclei  have  evidently  disappeared. 

>  Leyden.    Klinik  der  Eiickenmarkskrankheiten.     Bd.  II.  (2,  Taf.  V.,  Fig.  3), 
1877,  p.  516. 

^  Fox  {A.  W.).    The  British  Medical  Journal.    Vol.  I.,  1881,  p.  83. 


SPINAL   CORD   AND   MEDULLA   OBLONGATA.  981 

described,  but  they  appear  to  be  quite  secondary  to  the  altera- 
tions in  the  ganglion  cells.  The  pyramidal  tracts  have  often 
been  found  diseased,  and  the  degeneration  could  generally  be 
traced  into  the  pons  and  downwards  into  the  antero-lateral 
columns  of  the  cord;^  but  such  cases  are  not  pure  examples  of  the 
disease.  The  bulbar  affection  is  often  associated  with  diseases  of 
the  spinal  cord,  such  as  progressive  muscular  atrophy  and  amyo- 
trophic lateral  sclerosis.  The  roots  of  the  bulbar  nerves  are 
almost  always  atrophied,  and  degenerative  changes  have  been 
found  in  the  nerves  themselves.  The  muscles  atrophy  and 
undergo  the  same  degenerative  changes  which  are  observed  in 
progressive  muscular  atrophy.  When  the  disease  extends  into 
the  spinal  cord,  the  ganglion  cells  of  the  anterior  cornua  are 
diseased  in  the  same  manner  as  in  progressive  muscular  atrophy. 
When  the  cord  is  affected  the  spinal  nerves  issuing  from  the 
diseased  portions  and  the  muscles  to  which  they  are  distributed 
are  involved  in  morbid  action, 

§  439.  Diagnosis  and  Prognosis. — When  bulbar  paralysis  is 
fully  developed,  the  symptoms  are  so  characteristic  that  it  is 
hardly  possible  to  mistake  them,  but  the  onset  of  the  disease  is 
often  very  insidious.  The  patient  may  complain  of  a  feeling  of 
pressure  and  traction  in  the  back  of  the  neck,  and  a  slight  nasal 
resonance  of  the  voice,  these  being  frequently  the  first  symptoms 
to  attract  attention.  On  closer  examination  it  may  be  observed 
that  there  is  a  slight  alteration  in  the  expression  of  the  face,  and 
a  certain  degree  of  stiffness  of  the  lips,  causing  some  imperfection 
of  articulation,  and  that  the  tongue  trembles  on  protrusion. 

In  the  fully-established  disease  the  difficulty  is  to  distinguish 
between  the  primary  and  secondary  forms  of  the  affection, 
and  there  can  be  little  doubt  that  many  of  the  cases  which 
have  been  described  under  the  name  of  labio-glosso-laryngeal 
paralysis  really  belong  to  the  latter  category.^  The  diagnosis 
must  be  made  from  a  careful  investigation  into  the  history  of  the 
case,  and  the  order  of  development  of  all  the  symptoms.     The 

^  See  Benedikt.  "Ein  Fall  von  diffuser  Neuritis  centralis."  Deutsches  Arch. 
f.  klin.  Med.,  Bd.  XIIL,  1874,  p.  94  (Tafel  L-V.). 

'■'See  Cheadle.  "Labio-glosso-laryngeal  paralysis."  St.  George's  Hospital 
Keports,  Vol.  V.,  1872  (Case  I.),  p.  125. 


982  SYSTEM  DISEASES  OF  THE 

manner  in  which  the  primary  disease  begins  is  the  best  guide  to 
distinguish  it  from  embolism,  thrombosis,  and  haemorrhage  in 
the  medulla.  These  lesions  always  commence  suddenly,  and 
the  resulting  paralysis  is  frequently  unilateral  or  more  pro- 
nounced on  one  side  than  on  the  other,  while  progressive  bulbar 
paralysis  is  always  gradual  in  its  onset,  and  the  paralysis  is 
uniformly  bilateral.  Bulbar  paralj'sis  sometimes  results  from 
disease  situated  in  the  cerebral  hemispheres,  but  the  difference 
between  this  form  and  the  progressive  affection  will  be  sub- 
sequently described. 

The  prognosis  is  always  grave,  and  it  is  most  likely  that  all 
genuine  cases  of  the  progressive  disease  terminate  fatally.  In  a 
case  at  present  under  my  care  the  symptoms  of  bulbar  paralysis 
supervened  somewhat  suddenly  in  association  with  ulceration  of 
the  leg  and  other  manifestations  of  tertiary  syphilis,  and  the 
patient  has  made  almost  a  complete  recovery,  under  active 
antisyphilitic  treatment,  so  far  as  the  bulbar  symptoms  are 
concerned.  In  this  case,  however,  the  patient  still  suffers  from 
some  degree  of  anaesthesia  of  the  soles  of  the  feet,  and  the 
patellar-tendon  reactions  are  absent,  and  it  is  probable  that 
these  symptoms  will  develop  into  locomotor  ataxia.  An  aggra- 
vated case  of  bulbar  paralysis  of  uncertain  origin  is  recorded 
by  Dr.  Dowse ^  which  made  an  almost  complete  recovery ;  but 
although  exceptional  cases  of  this  kind  encourage  us  not  to 
abandon  all  hope  even  in  severe  cases,  yet  it  must  be  confessed 
that  the  prognosis  is  always  a  gloomy  one. 

§  440.  Treatment. — The  treatment  of  true  progressive  bulbar 
paralysis  has  hitherto  proved  of  little  avail,  but  much  may  be 
done  to  add  to  the  comfort  of  the  patient  and  probably  to  delay 
the  progress  of  the  disease.  Nothing  should  be  left  undone 
which  tends  to  improve  the  general  health  of  the  patient. 

The  special  remedies  which  have  been  employed  in  the 
treatment  of  the  disease  are  nitrate  of  silver,  iodide  of  potas- 
sium, iodide  of  iron,  chloride  of  gold  and  sodium,  ergotine,  and 
belladonna;  but  unless  there  is  any  special  indication  for  the 
administration  of  iodide  of  potassium  I  should,  myself,  follow 

'  Dowse  (J.  S.).    The  Lancet.    Vol.  T.,  1876,  p.  349. 


SPINAL   COED   AND  MEDULLA  OBLONGATA.  983 

the  advice  of  Dr.  Dowse,^  and  trust  to  phosphorus,  iron,  and 
cod-liver  oil.  He  also  recommends  the  subcutaneous  injection  of 
one-fortieth  of  a  grain  of  atropine  with  the  view  of  moderating 
the  excessive  flow  of  saliva,  and  in  the  case  which  has  already 
been  mentioned  as  having  recovered  under  him  he  combined 
one-sixth  of  a  grain  of  strychnine  with  the  atropine,  while  the 
constant  current  was  applied  to  the  paralysed  parts. 

Erb  advises  the  stabile  application  of  the  current  transversely 
through  the  mastoid  processes,  and  longitudinally  through  the 
skull;  also  galvanism  of  the  cervical  sympathetic,  by  placing 
the  anode  on  the  nucha  while  the  cathode  is  run  rapidly  over 
the  lateral  surface  of  the  larynx,  twelve  to  twenty  movements 
of  deglutition  being  induced  at  each  sitting.  The  galvanic 
or  faradic  current  may  be  applied  to  the  tongue,  lips,  and 
palate. 

As  the  power  of  deglutition  becomes  more  and  more  impaired, 
the  food  must  be  carefully  selected  and  finely  divided,  and  finally 
the  patient  must  be  fed  through  a  tube.  Care  should  be  taken 
to  wash  the  mouth  after  eating,  and  to  remove  particles  of  food 
which  lodge  about  the  pharynx  and  underneath  the  tongue. 

(7)  Ophthalmoplegia  Externa  vel  Progressiva. 

The  essential  phenomena  of  this  disease  are  caused  by  a  pro- 
gressive paralysis  of  the  ocular  muscles,  which  appears  to  run  a 
course  more  or  less  similar  to  the  progressive  paralysis  of  the 
lips,  tongue,  and  soft  palate,  which  has  just  been  described.  The 
disease  was  first  described  by  von  Graefe,^  and  it  has  in  recent 
times  been  carefully  investigated  by  Mr.  Jonathan  Hutchinson,^ 
while  cases  of  the  affection  have  been  recorded  by  Dr.  Sturge* 
and  by  Dr.  Buzzard.^ 

Etiology. — The  two  known  causes  of  the  disease  are  syphilis 
and  rheumatism.      Out  of  seventeen  cases   described   by  Mr. 

'  Dowse.     "  Bulbar  paralysis."    British  Medical  Journal,  Vol.  II.,  1876,  p.  616. 

^See  Eulenburg  (A.).  Lehrbuch  der  Nervenkrankheiten.  2  Aufl.,  Theil.  XL, 
1878,  p.  67.  .  ' 

^  Hutchinson.  "  Symmetrical  immobility  (partial)  of  the  eyes  with  ptosis 
(exophthaimoplegia  externa)."  Medico-Chir.  Transactions,  Vol  LXII.,  1879, 
p.  360. 

*  Sturge.  "  Two  cases  of  simultaneous  paralysis  of  both  third  nerves."  Ophth. 
Soc.  Transactions,  Vol.  I. 

•>  Buzzard  (T.).     Diseases  of  the  Nervous  System.     1882.    p.  180. 


984  SYSTEM  DISEASES   OF  THE 

Hutchinson  ten  were  syphilitic,  the  disease  being  acquired  in 
eight  and  inherited  in  two.  And  of  the  seven  remaining  a 
reasonable  suspicion  of  syphilis  might  be  entertained  in  several. 
Two  cases  are  recorded  by  Buzzard;  one  of  them  was  syphilitic, 
and  the  other  had  rheumatic  fever  over  nine  years  before  the 
ocular  symptoms  began. 

Symptoms. — The  first  symptom  to  attract  attention  is,  as  a 
rule,  drooping  of  the  eyelids,  which  gives  to  the  patient  a  peculiar 
sleepy  appearance.     Soon  afterwards  all  the  muscles  of  the  eye- 
balls manifest  signs  of  weakness,  as  evinced  by  the  restricted 
movements  of  the  eyeballs,  but  the  paralysis  gradually  increases 
until  ultimately  the  globes  are  completely  immovable.      The 
paralytic  condition  is  usually  bilateral,  but  the  nerves  are  not 
always  affected  simultaneously  or  to  the  same  degree,  so  that 
the  muscular  paralysis  may  present  every  possible  combination ; 
but,  as  Hutchinson  remarks,  implication  of  the  muscles  in  groups 
and  not  singly  is  a  marked  feature  of  the  disease.    The  pupils  are, 
as  a  rule,  in  a  medium  state  of  dilatation,  and  Mr.  Hutchinson 
found  them  almost  always  sluggish,   while   in   the   two   cases 
recorded  by  Dr.  Buzzard  there  was  reflex  immobility  of  the 
pupils  to  light.     The  state  of  accommodation  could  not  always 
be  tested,  but  in  some  cases  it  was  found  normal.     In  one-third 
of  the  cases  reported  by  Mr.  Hutchinson  there  was  blindness 
with   white   atrophy  of  the  optic  nerves.     In  some  cases  the 
trigeminal  nerves,  and  in  others  the  facial  nerves,  were  impli- 
cated, while  in  one  of  Mr.  Hutchinson's  cases  the  palate  was 
affected  and  smell  was  lost.     In  a  case  which  I  had  an  oppor- 
tunity of  examining  through  the  kindness  of  Dr.  Emrys  Jones 
there  was  double  ptosis,  great  restriction  of  all  the  movements 
of  the  eyeball,  and  almost  complete  insensibility  of  the  con- 
junctiva on  both  sides.     There  was  no  anaesthesia  in  any  other 
part  of  the  distribution  of  the  fifth  nerves,  the  movements  of  the 
pupils   were  normal,   and   the   patellar-tendon   reactions   were 
present.     The  patient  was  a  healthy  looking  young  woman  of 
twenty-two   years    of  age ;   the  symptoms  crept  on  gradually 
without  apparent  cause,  and  no  evidence  of  syphilis  could  be 
detected.      In  one  of  the  cases  recorded  by   Dr.  Buzzard  the 
muscles  about  the  back  and  shoulders  were  decidedly  atrophied, 
while  six  of  Mr.  Hutchinson's  cases,  and  both  those  recorded  by 


SPINAL   CORD  AND   MEDULLA  OBLONGATA,  985 

Dr.  Buzzard,  suffered  from  one  or  more  of  the  sj^mptoms  of 
locomotor  ataxia,  such  as  lancinating  pains  and  other  sensory- 
disorders  in  the  lower  extremities,  absence  of  the  patellar-tendon 
reaction,  reflex  immobility  of  the  pupil,  swaying  movements  on 
closing  the  eyes,  or  ataxic  gait. 

Morbid  Anatomy  and  Physiology. — In  one  of  the  cases 
recorded  by  Mr.  J.  Hutchinson  a  post-mortem  examination  was 
obtained,  and  Dr.  Gowers  found  degeneration  of  the  roots  of  the 
ocular  nerves,  and  disappearance  of  the  cells  from  their  nuclei  of 
origin.  A  post-mortem  examination  was  also  obtained  in  one  of 
Dr.  Buzzard's  patients,  who  in  addition  to  the  paralysis  of  the 
ocular  muscles  had  suffered  from  the  symptoms  of  advanced 
locomotor  ataxia.  The  usual  changes  observed  in  ataxia  were 
found  in  the  posterior  columns  of  the  spinal  cord  by  Dr.  Bevan 
Lewis,  who  conducted  the  microscopical  examination  of  the 
nervous  tissues ;  he  also  found  extensive  structural  alterations 
in  the  nuclei  of  the  sixth  and  in  the  ascending  roots  of  the  fifth 
nerves. 

It  would  seem,  then,  to  be  certain  that  the  essential  lesion  in 
this  affection  is  a  chronic  degeneration  of  the  nuclei  of  origin  of 
the  ocular  motor  nerves.  The  affection  is,  therefore,  closely 
allied  to  bulbar  paralysis,  and  both  of  them  stand  in  close  rela- 
tionship, both  in  their  morbid  anatomy  and  clinical  histories  with 
progressive  muscular  atrophy.  That  ophthalmoplegia  externa 
and  locomotor  ataxia  should  be  frequently  associated  is  not 
strange  when  the  relation  of  both  affections  to  syphilis  is  kept 
in  view,  and,  as  already  remarked,  bulbar  paralysis  of  syphilitic 
origin  may  be  complicated  by  some  of  the  symptoms  of  loco- 
motor ataxia. 

Diagnosis  and  Prognosis. — The  presence  of  double  ptosis 
and  the  more  or  less  symmetrical  implication  of  the  muscles 
supplied  by  all  the  ocular  motor  nerves  on  both  sides  renders  the 
diagnosis  easy.  The  prognosis  is  by.  no  means  unfavourable  in 
the  syphilitic  variety  of  the  disease,  provided  the  patient  be 
subjected  to  treatment  before  the  ocular  paralysis  is  complicated 
by  locomotor  ataxia,  or  other  grave  nervous  disorder.  According 
to  Mr.  Hutchinson,  however,  recovery  is  never  complete. 

Treatunent. — The  treatment  is  the  same  as  when  the  ocular 
motor  nerves  are  separately  affected.    If  any  trace  of  syphilis  be 


986  SYSTEM  DISEASES  OF  THE 

detected,  iodide  of  potassium  must  be  administered.  This  drug 
also  gives  most  promises  of  success  in  the  early  stages  of  cases 
unconnected  with  syphilis. 


§  441.  Localisation  of  the  Lesion  in  the  Atrophic  Forms  of 
Spinal  Paralysis. 

Having  now  come  to  the  end  of  our  remarks  upon  tlie  diseases  which 
are  Umited  to  the  grey  substance  of  the  spinal  cord,  it  may  not  be  out  of 
place  if  we  enter  upon  a  brief  consideration  of  the  localisation  of  the  lesion. 
The  reason  why  we  regard  this  place  as  the  end  of  the  diseases  of  the  grey 
substance  is  that  pseudo-hypertrophic  paralysis,  which  will  be  immediately 
described,  is  not,  in  our  opinion,  a  primary  nervous  affection.  The  chief 
symptom  of  all  the  diseases  which  we  have  so  far  discussed  in  this  chapter 
is  paralysis  of  varying  degrees  of  intensity.  The  paralysis  in  the  affections 
which  we  are  considering  is  caused  by  disease  of  the  motor  gangUon  cells, 
or  of  the  outgoing  fibres  which  connect  them  with  the  muscles.  The 
paralysis  is,  as  a  rule,  associated  with  wasting  of  the  affected  muscles,  but 
it  is  important  to  observe  that  the  two  symptoms  are  not  invariably  asso- 
ciated. We  have  already  found  grounds  for  believing  that  the  most  pro- 
nounced forms  of  atrophy  occur  when  the  muscles  are  separated  from  the 
earlier  formed  and  fundamental  cells,  and  that  a  profound  trophic  disorder 
is  not  likely  to  follow  separation  of  the  muscles  from  the  accessory  cells. 
Acute  atrophic  spinal  paralysis  may  be  supposed  to  be  caused  by  an  acute 
inflammation  of  the  grey  substance  either  beginning  in  the  anterior  horns 
or  soon  extending  to  them,  and  producing  rapid  destruction  of  the  motor 
ganglion  cells  and  of  the  fibres  which  issue  from  these  to  pass  out  in  the 
anterior  roots.  We  shall  not  wait  to  inquire  whether  the  inflammation 
begins  in  the  nervous  tissues  or  in  the  neuroglia  and  blood-vessels,  inasmuch 
as  we  do  not  consider  the  question  of  any  special  consequence  to  nervous 
pathology,  although  it  may  be  one  of  great  interest  and  importance  to 
general  pathology.  It  wiU  sufiice  for  our  pm-pose  to  say  that  in  acute 
atrophic  spinal  paralysis  the  affected  muscles  are  suddenly  separated  from 
their  trophic  centres  in  the  spinal  cord  either  by  a  destructive  lesion  of  the 
trophic  cells  themselves  or  of  the  fibres  which  unite  them  with  the  muscles. 
It  is  clear  that  an  acute  process  such  as  we  have  described  is  likely  to  sever 
the  muscles  from  the  fundamental  as  well  as  from  the  accessory  cells,  and 
consequently  the  muscular  paralysis  which  results  is  very  similar  to  that 
which  is  met  with  in  lesions  of  the  peripheral  nerves  themselves.  If  we 
now  compare  Landr/s  paralysis,  chronic  atrophic  spinal  paralysis,  peri- 
ependymal myelitis,  and  progressive  muscular  atrophy,  it  is  impossible  not 
to  be  struck  with  the  essential  unity  which  underlies  them.  These  diseases 
are  characterised  by  a  progressively-invading  paralysis  which  may  pursue 
an  ascending  or  a  descending  course,  and  by  an  almost  entire  absence  of 
sensory  disturbances,  bed-sores,  and  paralysis  of  the  sphincters.     And  the 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  987 

differences  existing  between  these  diseases  are  no  less  instructive,  the  most 
striking  of  them  depending  upon  the  time  occupied  in  the  development  and 
progress  of  the  symptoms.  Landry's  paralysis  is  sudden  in  its  onset  and 
rapid  in  its  progress ;  while  progressive  muscular  atrophy  is,  on  the  contrary, 
gradual  in  its  onset  and  slow  in  its  progress,  and  the  other  two  diseases 
occupy  intermediate  positions  between  them  with  respect  to  their  rapidity 
of  development  and  duration.  In  Landry's  paralysis  there  is  no  decided 
muscular  atrophy,  and  the  faradic  contractility  of  the  affected  muscles 
remains  nearly  normal ;  in  chronic  atrophic  spinal  paralysis  there  is  decided 
muscular  atrophy,  rapid  loss  of  faradic  contractility,  and  the  reaction  of 
degeneration ;  in  periependymal  myelitis  there  is  also  pronounced  atrophy, 
and  the  faradic  contractility  becomes  slowly  and  gradually  diminished; 
and  in  progressive  muscular  atrophy  the  wasting  of  the  muscles  and 
paralysis  of  them  proceed  side  by  side,  and  the  faradic  contractihty  is 
normal,  or  only  slightly  diminished,  so  long  as  any  muscle  remains.  We 
have,  however,  seen  that  transitional  cases  exist  which  it  is  scarcely 
possible  to  classify.  It  appears  to  me  that  Landry's  paralysis,  chronic 
atrophic  spinal  paralysis,  periependymal  myehtis,  and  progressive  mus- 
cular atrophy  are  only  different  forms  of  inflammation  of  the  central 
grey  column  of  the  cord.  In  Landry's  paralysis  the  inflammatory 
process  is  very  acute,  and  remains  chiefly  limited  to  the  central  colmnn 
with  anterior  and  lateral  extensions  into  the  embryonic  areas  of  the 
anterior  grey  horns.  According  to  this  view  the  muscles  would  for  a  long 
time  maintain  their  connection  with  the  fundamental  cells,  and  thus  their 
nutrition  and  faradic  contractihty  woidd  remain  comparatively  unaffected. 
An  inflammatory  action  of  this  kind  may  be  supposed  to  spread  rapidly 
along  the  central  canal  and  the  surrounding  tissues,  just  as  erythema  or 
erysipelas  is  known  to  extend  along  the  surface  of  the  body,  and  this  would 
explain  the  ascending  or  descending  course  which  is  pursued  by  the  disease. 
The  morbid  process  pxxrsues  the  same  ascending  or  descending  course  in 
chronic  atrophic  spinal  paralysis,  but  in  this  affection  the  fundamental 
ganglion  cells  are  invaded  and  destroyed,  and  consequently  the  muscles 
undergo  atrophy  and  lose  their  faradic  contractility.  Periependymal 
myelitis  pursues  a  somewhat  similar  course  to  the  chronic  atrophic  variety, 
but  in  it  the  posterior  columns  and  posterior  horns  are  encroached  upon, 
and  some  degree  of  anaesthesia  is  hable  to  be  associated  with  the  muscular 
paralysis.  In  progressive  muscular  atrophy  the  disease  appears  to  be  a 
parenchymatous  one,  and  to  spread  from  nerve  fibre  to  nerve  fibre  and 
from  ganglion  ceU  to  ganghon  cell.  The  morbid  process  appears  to  begin 
in  the  small  cells  and  fine  fibres  which  he  nearest  to  the  central  canal,  and 
gradually  to  spread  upwards,  downwards,  and  laterally.  In  its  lateral 
extension  the  ganglion  cells  which  were  last  developed  are  the  first  to 
become  affected,  and  the  fundamental,  cells  are  only  invaded  after  a  long 
period  of  time.  It  will  be  apparent  that  in  such  a  gradual  process  as  this 
the  muscular  paralysis  and  atrophy  w411  pursue  a  parallel  course,  and  that 
the  faradic  contractility  will  be  maintained  so  long  as  the  fundamental  cells 


988  SYSTEM  DISEASES   OF  THE 

are  able  to  perform  their  functions  even  imperfectly,  and  long  after  they 
have  become  partially  diseased. 

We  must  now  endeavom*  to  ascertain  the  localisation  of  the  lesion  in 
the  atrophic  paralysis  in  the  longitudinal  axis  of  the  spinal  cord.  Speaking 
broadly,  it  may  be  said  that  the  muscles  of  the  lower  extremities  are  affected 
when  the  lesion  is  situated  in  the  lumbar  enlargement ;  those  of  the  back 
and  abdomen  when  it  is  situated  in  the  dorsal  region ;  those  of  the  upper 
extremities  when  in  the  cervical  enlargement ;  those  of  the  neck  when  in 
the  upper  cervical  region ;  those  of  the  lips,  tongue,  and  palate  when  in 
the  medulla  oblongata;  and  the  ocular  muscles  when  it  is  situated  in  the 
nuclei  of  the  crura  cerebri  and  pons.  It  is,  however,  very  desirable  to 
ascertain,  if  possible,  the  level  of  the  lesion  with  still  greater  exactitude, 
and  more  especially  when  it  is  situated  in  the  cervical  and  lumbar  enlarge- 
ments. In  the  spinal  atrophic  paralyses  the  muscles,  as  has  been  shown  by 
Remak,  are  paralysed  in  groups,  according  as  they  are  associated  in  their 
actions,  and  it  may  consequently  be  inferred  that  particular  groups  of 
muscles  will  be  represented  in  the  cord  by  ganglion  cells  which  lie  near  to 
each  other.  We  have  already  seen  (§  291)  that  the  deltoid,  biceps, 
brachialis  anticus,  and  long  and  short  supinator  are  innervated  from  the 
motor  root  of  the  fifth  cervical  nerve,  and  these  muscles  are  almost  always 
simultaneously  paralysed  in  spinal  lesions  of  the  grey  substance.  In  pro- 
gressive muscular  atrophy,  for  instance,  it  may  be  inferred  that  the  biceps 
and  supinator  longus  will  soon  be  affected  if  the  slightest  trace  of  atrophy 
is  discovered  in  the  deltoid  muscle ;  and,  conversely,  it  may  be  inferred  that, 
if  in  any  of  the  atrophic  paralyses  the  deltoid  shows  signs  of  amendment, 
the  other  muscles  of  the  group  will  also  soon  begin  to  recover.  Post- 
mortem examinations  have  not  yet  thrown  much  light  upon  this  question. 
In  a  case  of  adult  spinal  paralysis  observed  by  Schultze^in  a  man  aged 
forty-two  years,  some  of  the  muscles  of  the  left  upper  extremity  were 
paralysed  along  with  a  more  extensive  implication  of  the  muscles  of  the 
lower  extremities.  The  shoulder  muscles  and  the  rhomboids  of  the  left 
side  were  atrophied,  the  trapezius  was  degenerated  to  a  less  degree,  the 
deltoid  was  completely  degenerated,  the  supinator  longus  was  considerably 
altered,  while  the  biceps  and  triceps  were  said  to  have  been  normal.  On 
post-mortem  examination  of  the  spinal  cord  the  left  anterior  horn  was 
reduced  to  about  one-third  the  volume  of  the  corresponding  right  horn  in 
the  upper  segment  of  the  cervical  enlargement.  It  would  appear  from  this 
case,  therefore,  that  the  muscles  affected  in  the  upper  extremity  were  inner- 
vated from  the  level  of  the  fourth  and  fifth  nerves.  Simultaneous  paralysis 
of  the  deltoid,  biceps,  brachialis  anticus,  and  supinator  longus  is  named 
by  Kemak  "the  upper  arm  type"  of  atrophic  paralysis,  but  Ferrier,^  who 

1  Schultze.  "Beitrage  zur  Pathologie  und  pathologisclien  Anatomie  des  centralen 
Nervensystems,  insbesondere  des  Ruckenmarkes."  Virchow's  Arch.,  Bd.  LXXIII., 
1878,  p.  444, 

*  Ferrier.  "The  localisation  of  atrophic  paralyses."  Brain,  Vol.  IV.,  1882, 
pp.  217,  303. 


SPINAL    CORD   AND   MEDULLA   OBLONGATA.  989 

recognises  as  many  types  of  atrophic  paralysis  in  the  extremities  as  there 
are  spinal  segments  and  motor  roots  to  supply  their  muscles,  regards  this 
combination  of  muscular  paralysis  as  the  "  type  of  the  fifth  cervical  roots." 
In  the  "fourth  cervical  type"  the  diaphragm,  rhomboids,  supra  and  infra- 
spinati,  teres  minor,  and  the  posterior  third  of  the  deltoid  are  the  muscles 
which  are  principally  affected,  although  the  remaining  portion  of  the  deltoid, 
the  biceps,  brachialis  anticus,  and  supinator  longus  may  be  affected  to  a 
lesser  degree.  The  next  group  concerning  the  innervation  of  which  we 
possess  anything  like  accurate  knowledge  consists  of  the  intrinsic  muscles 
of  the  hand,  the  long  flexors  of  the  fingers,  and  the  flexors  of  the  wrist.  We 
have  already  seen  (§  291)  that  these  muscles  are  innervated  from  the  eighth 
cer^dcal  and  first  dorsal  nerves.  A  case  of  infantile  paralysis  is  recorded 
by  Seeligmiiller^  in  which  these  muscles  were  paralysed  and  it  is  probable 
that  the  lesion  was  situated  on  a  level  with  the  eighth  cervical  and  first 
dorsal  nerves. 

A  very  interesting  case  of  paralysis  of  the  intrinsic  muscles  of 
the  hand  has  been  described  by  Prevost  and  David.  ^  It  was  that 
of  a  man,  aged  sixty  years,  who  suffered  from  febrile  and  typhoid 
symptoms,  which  caused  his  death.  The  man  had  complete  atrophy 
of  the  muscles  of  the  thenar  eminence  of  the  right  hand,  which, 
according  to  his  own  account,  came  on  in  childhood.  The  anterior  root 
of  the  eighth  cervical  nerve  of  the  right  side  was  notably  diminished  in  size, 
as  compared  with  that  of  the  left  side,  and  the  anterior  root  of  the  seventh 
nerve  was  also  sHghtly  diminished  in  volume  on  the  right  side.  Opposite 
the  atrophied  root  of  the  eighth  nerve  the  anterior  horn  on  the  same  side 
was  observed  to  be  sensibly  diminished  as  compared  with  that  of  the  left. 
The  diseased  portion  had  a  longitudinal  extent  of  about  two  centimetres, 
and  the  centre  of  the  lesion  was  on  a  level  with  the  atrophied  root.  Its 
greatest  transverse  extent  was  also  opposite  the  diseased  root  of  the  nerve 
and  it  gradually  diminished  in  size,  both  upwards  and  downwards.  The 
author  says  that  in  the  diseased  portions  the  external  or  lateral  (postero- 
lateral) group  were  represented  by  a  few  healthy  cells,  while  the  anterior 
(antero-lateral)  and  the  middle  or  internal  (internal)  groups  were  normal. 
Judging  from  the  drawing,  however,  the  median  and  central  groups  were 
entirely  destitute  of  cells,  while  the  antero-lateral  group  was  only  repre- 
sented by  one  cell. 

A  case  of  extreme  muscular  atrophy  is  reported  by  Dr.  Zach.  Johnson, 
in  which  the  muscles  of  the  shoulder  and  arm  had  completely  disappeared, 
but  inasmuch  as  only  the  lower  third  of  the  cervical  enlargement  of  the 
cord  was  examined  by  Dr.  Lockhart  Clarke,^  it  would  not  be  safe  to  make 
a  definite  inference  from  the  changes  described. 

We  do  not  possess  any  accurate  clinical  information  with  regard  to  the 

1  Seeliginiiller.  "Ueber  Lahmungen  im  Kindesalter."  Jahrb.  fiir  Kinderheilk., 
N.F.,  Bd.  XIII.,  1879,  p.  333. 

*  Erevost  and  David.     Archiv.  de  physiologie.     Serie  II.,  Tome  I.,  1874,  p.  595. 
^  Clarke  and  Johnson.    Medico-Chirurgie^l  Transactions.    Vol.  LI.,  ]868,  p.  2i9. 


990  SYSTEM  DISEASES   0¥  THE 

muscles  whicla  are  paralysed  when  the  lesion  is  situated  on  a  level  with  the 
sixth  or  seventh  cervical  nerves,  but  a  case  of  somewhat  extensive  atrophy 
of  the  muscles  of  the  right  arm  is  recorded  by  Eisenlohr^  which  throws  some 
light  upon  this  question.  The  patient  was  the  subject  of  paralysis  and 
atrophy  of  a  number  of  the  muscles  of  the  right  upper  extremity.  The 
extensors  of  the  forearm  and  the  triceps  were  completely  paralysed  and 
atrophied  ;  the  serratus  magnus  and  pectoralis  major  were  also  deeply 
involved  ;  and  the  deltoid,  and  pronators  and  flexors  of  the  forearm  and  the 
intrinsic  muscles  of  the  hand  were  weak  and  somewhat  wasted,  but  the 
supinator  longus  and  the  biceps  were  healthy.  After  death  the  right 
anterior  cornu  was  found  diseased  from  the  level  of  the  sixth  cervical  to 
the  first  dorsal  roots.  At  the  upper  part  of  the  lesion  the  disease  was 
limited  to  the  postero-lateral  group  of  cells,  and  the  sixth  root  contained 
healthy  and  diseased  fibres.  From  the  level  of  the  lowest  fibres  of  the 
sixth  down  to  that  of  the  eighth  root  the  whole  of  the  anterior  horn 
was  diseased,  although  even  here  the  lateral  part  of  the  horn  was 
the  most  altered,  and  the  eighth  anterior  root  is  said  to  have  contained 
numerous  degenerated  fibres.  The  escape  of  the  flexors  of  the  arm  and 
supinator  longus  shows  that  they  are  innervated  above  the  level  of  the 
sixth  roots,  and  we  already  know  that  they  derive  their  nerve  supply  from  the 
fifth  cervical  nerve.  The  complete  paralysis  of  the  triceps  and  extensors  of 
the  forearm  shows  that  they  are  innervated  from  the  sixth  to  the  eighth 
roots.  The  partial  paralysis  of  the  pectoralis  major  and  serratus  magnus 
shows  that  they  also  derive  a  portion  at  least  of  their  nerve  supply  from 
the  sixth  to  the  eighth  roots.  The  partial  implication  of  the  deltoid  muscle 
is  difficult  to  explain,  but  the  partial  paralysis  of  the  pronators  of  the  fore- 
arm, the  long  flexors  of  the  fingers,  and  of  the  muscles  of  the  hand,  is  quite 
compatible  with  the  opinion  already  advanced  that  they  are  innervated 
from  the  eighth  cervical  and  first  dorsal  nerves. 

Our  information  vdth  regard  to  the  distribution  of  the  paralysis  when 
the  lesion  is  situated  in  the  lumbar  enlargement  is  even  scantier  than  when 
it  is  in  the  cervical  enlargement.  The  little  information  we  possess  is 
chiefly  derived  from  our  knowledge  of  the  functions  of  the  motor  roots  of 
the  sacral  and  coccygeal  nerves  (§  297). 

It  has  been  pointed  out  by  Eemak^  and  others  that  the  sartorius  gene- 
rally escapes  in  a  local  disease  of  the  cord  in  the  lumbar  region,  wliich 
paralyses  the  other  muscles  supplied  by  the  anterior  crural  nerve.  The 
sartorius  is  functionally  related  to  the  flexors  of  the  thigh  on  the  pelvis 
and  the  flexors  of  the  leg  on  the  thigh,  and  it  is  therefore  likely  to  be 
paralysed  along  with  the  psoas  and  iliacus  or  vsdth  the  flexors  of  the  leg  on 
the  thigh,  and  not  with  the  extensors  of  the  leg  on  the  thigh.     It  has  been 

*  Eisenlohr.  "Poliomyelitis  anterior  suhacuta  cervicalis  circumscripta  beim 
Erwachsenen."    Neurologische  Centralbl.,  Bd.  I.,  1882,  p.  410. 

^  See  Eemak.  "  Zur  Pathogenese  der  Bleilahmungen,"  Arch.  f.  Psychiatric, 
Bd.  VI.,  1875,  p.  1 ;  uid  "Ueber  die  Localisation  atropischer  Spinallahmungen 
und  Spinaler  Muskelatrophieen,"  Ibid,,  Bd.  IX.,  1879,  p.  510. 


SPINAL  CORD  AND  MEDULLA  OBLONGATA.  991 

suggested  by  Eemak  that  the  tibialis  anticus  is  likely  to  be  paralysed  along 
with  the  extensors  of  the  leg  on  the  thigh,  and  to  be  spared  when  the 
remaining  anterior  muscles  of  the  leg  are  paralysed,  and  he  beheves  it  to 
correspond  in  this  respect  with  the  supinator  longus  in  the  upper  extremity, 
which  is  associated  in  its  paralyses  with  the  muscles  of  the  arm,  and  not 
with  those  of  the  forearm. 

A  case  has  been  described  by  Kahler  and  Pick^  which  appears  to 
determine  the  localisation,  in  the  anterior  horns,  of  the  spinal  centres 
for  the  muscles  of  the  calf  of  the  leg.  The  case  was  that  of  a  woman, 
twenty-four  years  of  age,  who  died  from  an  attack  of  typhoid  fever.  The 
muscles  of  the  calf  of  the  right  leg  were  found  almost  completely  atrophied. 
On  examination  of  the  spinal  cord  the  right  anterior  grey  horn  was  found 
atrophied  through  the  greater  portion  of  the  lumbar  enlargement,  but  the 
most  marked  changes  were  observed  on  a  level  with  the  fourth  and  fifth 
sacral  nerves.  The  roots  of  these  nerves  were  also  atrophied,  there  was  a 
slight  increase  of  the  interstitial  connective  tissue,  which  was  especially 
well  marked  in  some  bundles.  The  central  group  of  cells  was  mainly 
aflfected. 

In  the  case  of  atrophic  spinal  paralysis  of  adults,  observed  by  Schultze,^ 
the  muscles  in  the  regions  of  distribution  of  the  sciatic  nerve  in 
both  legs  were  completely  paralysed,  while  those  supplied  by  the 
obturator  and  crural  nerves  were  spared.  Schultze  found  sclerosis 
of  both  anterior  horns  over  the  whole  of  the  lower  half  of  the  lumbar 
region,  and  he  consequently  concluded  that  the  crural  and  obturator  nerve 
nuclei  do  not  lie  in  the  lower  half  of  the  lumbar  region  of  the  cord.  Eemak, 
however,  thinks  that  the  tibiales  antici  were  also  spared  in  this  case,  and 
he  placed  the  nuclei  of  these  muscles  in  the  upper  half  of  the  lumbar  region 
of  the  cord. 

(8)  Pseudo-Hypertrophic  Paralysis. 

(Atrophia  Musculorum  Lipomatosa.) 

§  442.  Definition. — This  disease  is  characterised  by  feebleness 
of  the  muscles  of  the  lower  limbs  and  of  the  erector  muscles  of 
the  spine,  gradually  extending  to  those  of  the  upper  extremities. 
The  paralysis  is  accompanied  by  atrophy  of  some  of  the  muscles, 
and  by  an  apparent  increase  in  the  volume  of  others. 

§  443.  History. — Isolated  cases  of  this  disease  were  described  many  years 
ago  by  several  authors.    A  case  was  reported  by  Sir  Charles  Bell^  in  1830, 

*  Kahler  and  Pick.  "  Weifcere  Beitrage  zur  Pathologie  unci  pathologischen 
Anatomie  des  central  Nervensystems."  Archiv.  fiir  Psychiatrie,  Bd.  X.,  1880, 
p.  358. 

*  Schultze.    Virchow'8  Archiv.    Bd.  LXXIIL,  1878,  S.  444. 
'Bell.     On  the  nervous  system.    2nd  Edit.,  1830,  p.  clxiii. 


992  SYSTEM  DISEASES   OF  THE 

one  by  Coste  and  Gioja^  in  1838,  and  a  well  marked  case  by  Mr.  Partridge^ 
in  1847.  But  Dr.  Meryon,"  in  1852,  was  the  first  to  draw  attention  to  the 
clinical  featiu-es  of  this  aifection,  and  Oppenheimer,*  in  1855,  described  a 
well  marked  group  of  cases.  The  disease  was  thorovighly  investigated  by 
Duchenne.5  His  friend,  M.  Bouvier,  sent  to  his  clinique  in  1858  a  child, 
who  had  been  suffering  from  an  unusual  form  of  paralysis,  and  during  the 
subsequent  three  years  Duchenne  collected  other  cases,  which  were  similar 
to  the  one  sent  by  Bouvier,  and  yet  did  not  correspond  to  the  description  of 
any  known  disease.  Duchenne  described  the  principal  clinical  characters 
of  the  disease  in  the  second  edition  of  his  work  on  Localised  Electricity 
(Paris,  1861),  but  it  was  not  until  1868  that  he  jDublished  in  the  "  Ai'chives 
Generales  de  Medecine  "  a  full  account  of  his  investigations  into  the  nature 
of  the  affection.  He  then  gave  detailed  descriptions  of  thirteen  cases,  which 
had  come  under  his  own  observation,  and  incorporated  with  these  fifteen 
cases  published  up  to  that  date  by  other  observers.  So  thoroughly  was  the 
work  done  by  this  distinguished  physician  that  nothing  essential  has  since 
been  added  to  our  knowledge  of  the  course  and  progress  of  the  disease. 
Cases  have  been  described  in  this  country  by  Mr.  William  Adams,^  Dr. 
Langdon  Dovm,''  Dr.  Ord,®  Mr.  Kesteven,^  Drs.  Russell^"  and  Balthazar 
Foster^^  (Birmingham),  Dr.  Dyce  Brown,^^  Dr.  Barlow^^  (Manchester),  and 
Dr.  Davidson^*  (Liverpool),  Drs.  Gairdner^^  and  Macphail^^  (Glasgow),  and 


1  Coste  and  Gioja.  Ann  dell'  Osped.  degl.  Incur,  di.  NapoH,  1838 ;  Abstr. 
Schmidt's  Jahrbucb,  Bd.  XI.,  2,  p.  176. 

*  Partridge.    "Fatty  degeneration  of  muscle."    Medical  Gazette,  1847,  p.  944. 

^  Meryon.  "On  granular  and  fattv  degeneration  of  tbe  voluntary  muscles." 
Medico-Chirurgical  Transactions,  Vol.  XXXV.,  1852,  p.  73 ;  and  British  Medical 
Journal,  July  9,  1870. 

■*  Oppenheimer.  Ueber  progressive  fettige  Muskel- Atrophic,  1855 ;  Abstr. 
Canstatt's  Jahresb.,  Bd.  III.,  1855,  p.  77- 

*  Duchenne.  De  I'electrisation  localisee,  l™^  Edit.,  18G5  ;  and  "Eecherches  sur 
laparalysie  musculaire  p.seudo-hypertrophique,  ou  paralysie  myosclerotique."  Arch, 
gener.  de  m6d..  Vol.  I.,  1868,  pp.  5,  179,  305,  421,  and  552. 

"  Adams  (W.).  "  Case  of  progressive  muscular  atrophy,  associated  with  hyper- 
trophy, or  apparent  hypertrophy,  of  the  muscles  of  the  calf  of  the  leg."  Transactions 
of  the  Pathological  Societj',  Vol.  XIX.,  1868,  p.  11. 

'  Down  (Langdon).  "Case  of  paralysis,  with  apparent  muscular  hypertrophy." 
Transactions  of  the  Pathological  Society,  Vol.  XXI.,  1870,  p.  24 ;  and  Journal  of 
Mental  Science,  1870,  p.  46. 

^  Ord.  "  Notes  of  a  case  of  Duchenne's  pseudo-hypertrophic  muscular  paralysis, 
&c."  Medico-Chirurgical  Transactions,  Vol.  LVII.,  1874,  p.  11 ;  and  V^ol.  LX., 
1877. 

'  Kesteven.    Journal  of  Mental  Science.    Vol.  XVI.,  1871,  pp.  42  and  563. 

'0  Eussell.    Medical  Times  and  Gazette.    Vol.  I.,  1869,  p.  571. 

> '  Foster  (B.).     The  Lancet,  May  8,  1869,  and  April  18,  1874. 

**  Brown  (Dyce).    Edinburgh  Medical  Journal.    June,  1870.    p.  1079. 

'  ^  Barlow.    Liverpool  and  Manchester  Reports.     1876.     p.  I. 

^■*  Davidson.    Glasgow  Medical  Journal.     May,  1872. 

1*  Gairdner.     British  Medical  Journal.     Vol.  L,  1879,  p.  288 ;  and  Vol.  I,  1882, 
p.  618. 

' "  Macphail.      "  Pseudo-hypertrophic  paralysis  in  four  brothers."     The  Glasgow 
Medical  Journal,  July,  1882. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  993 

Dr.  Goodridge,^  -while  Dr.  Gowers^  lias  written  an  able  monograph,  on  the 
disease,  A  considerable  number  of  cases  have  also  been  published  in 
Germany  and  America, 

§  444.  Etiology. — This  affection  is  almost  but  not  exclusively 
confined  to  infancy.  The  first  symptoms  are  frequently  noticed 
at  the  time  when  the  child  ought  to  begin  to  walk,  although  it 
is  very  probable  that  the  disease  is  established  before  that  time. 
The  disease  begins  in  a  considerable  proportion  of  cases  between 
the  ages  of  five  and  thirteen  years,  and  cases  are  recorded  where 
adults  have  been  attacked.  It  may,  however,  be  doubted 
whether  many  of  the  latter  are  genuine  examples  of  the  disease. 
In  the  case  described  by  Auerbach,  for  instance,  the  hyper- 
trophy was  first  noticed  in  the  right  arm,  and  microscopical 
examination  of  the  affected  muscles  showed  that  the  disease 
was  a  genuine  hypertrophy.  In  the  case  described  by  Eulen- 
burg,'  where  the  patient,  a  female,  was  forty-four  years  of 
age  when  the  first  symptoms  appeared,  the  paralysis  began  in 
the  right  arm,  in  the  form  of  progressive  muscular  atrophy, 
and  although  there  was  apparent  hypertrophy  of  the  muscles 
of  the  lower  extremities,  the  course  and  progress  of  the  case 
was  different  from  those  of  a  case  of  true  pseudo -hypertrophic 
paralysis.  In  an  undoubted  instance  of  the  disease  under  my 
care  at  present  the  patient  is  forty-seven  years  of  age,  but  the 
affection  began  at  the  agje  of  ten.  It  is  much  more  common  in 
boys  than  girls.  Of  the  thirteen  cases  collected  by  Duchenne 
only  two  were  girls,  of  forty-one  cases, collected  by  Webber*  only 
five  were  females,  and  of  twenty-three  cases  mentioned  by  Dr. 
Gowers  only  five  were  females.  Out  of  a  total  of  220  cases 
hitherto  published  190  were  males  and  thirty  females  (Gowers). 
The  disease  also  appears  to  pursue  a  more  chronic  course  in  girls 
than  in  boys. 

Hereditary  predisposition  to  the  disease  frequently  exists.  Two 
children  in  the  same  family  are  often  attacked,  as  in  the  cases 

'  Groodridge  (H.  F.  A.).  "  Two  eases  of  pseudo-hypertrophic  muscular 
paralysis."    Brain,  Vol.  V.,  1882,  p.  268. 

'^  Gowers.    Pseudo-hypertrophic  muscular  paralysis.    Lond.,  1879. 

'  Eulenburg.  "  Ein  Fall  von  Lipomatosis  musculorum  luxurians  an  den  unteren 
und  progressiver  Muskelatrophie  an  den  oberen  Extremitaten."  Virchow's 
Archives,  Bd.  XLIX.,  1870,  p.  446. 

*  Webber.    Boston  Medical  and  Surgical  Journal.     Nov.  17,  1874. 

VOL.  L  LLL 


994  SYSTEM  DISEASES   OF  THE 

related  by  Heller/  Wernich,^  and  Kesteven,  and  sometimes  even 
eight  children  of  tbe  same  family  have  been  affected,  as  in  the 
cases  related  by  Meryon.  Lutz^  met  with  two  sisters,  a  maternal 
uncle  and  aunt,  and  a  maternal  half-sister,  issue  of  a  first  mar- 
riage, affected  with  the  disease.  In  another  example,  three 
maternal  uncles  and  aunts  were  affected ;  in  a  second,  a  maternal 
uncle  and  a  half-uncle;  in  a  third,  three  maternal  half-brothers; 
and  in  a  fourth  instance,  a  maternal  half-brother,  three  maternal 
uncles,  and  other  members  on  the  mother's  side.*  It  is  curious  to 
notice  that,  although  the  disease  is  mainly  confined  to  the  male 
sex,  yet  the  descent,  so  far  as  is  known,  is  always  through  the 
mother's  side.  This  disease  is  not,  as  a  rule,  transmitted  directly 
from  parents  to  offspring ;  since  by  far  the  greater  number  of  its 
victims  are  attacked  at  an  early  age,  and  therefore  do  not  become 
parents,  and  this  consideration  also  precludes  the  idea  that  it  is 
an  example  of  atavism.  A  certain  predisposition  is,  therefore, 
transmitted,  which,  with  the  concurrence  of  other  unfavourable 
circumstances,  such  as  an  eruptive  fever,  develops  the  disease. 

The  exciting  causes  of  the  disease  are  by  no  means  clear. 
Exposure  to  cold  and  damp  appears  to  be  occasionally  the  deter- 
mining cause,  while  at  other  times  it  has  followed  an  eruptive 
fever,  variola,  or  measles,  and  several  cases  have  been  ushered  in 
by  convulsions. 

§  445.  Symptoms. — Feebleness  of  the  lower  extremities  is 
usually  the  first  symptom  to  attract  attention,  and  when  the 
disease  begins  during  infancy  it  is  difficult  to  fix  the  exact  date 
of  its  origin.  The  attention  of  the  parents  is  not  directed  to  the 
condition  of  the  child  until  he  arrives  at  the  age  when  other 
children  begin  to  walk.  At  this  period  it  is  noticed  that  when  the 
child  is  placed  on  his  feet  he  does  not  instinctively  move  his  legs 
to  walk,  but  immediately  falls  down,  and  in  other  cases  he  may 
have  begun  to  walk,  but  is  soon  fatigued  and  can  no  longer  stand 

'Heller.  "  Klinische  Beobachtungen  iiber  die  bisher  als  '  Muskelhypertrophie ' 
bezeichnete  Lipomatosis  luxurians  musculorum  progressiva."  Deutsches  Arch.  f. 
klin.  Med.,  Bd.  I.,  1866,  p.  616. 

*  Wemich.  "Fall  von  Muskelhypertrophie."  Deutsches  Arch.  f.  klin.  Med., 
Bd.  II.,  1866,  p.  232. 

'  Lutz.  "Zwei  weitere  Falle  von  sogennanter  Muskelhypertrophie."  Deutsches 
Arch.  f.  klin.  Med.,  Bd.  III.,  1867,  p.  358. 

•*  Poore.    New  York  Medical  Journal.     1875. 


SPINAL   CORD  AND   MEDULLA  OBLONGATA.  995 

steadily  or  walk  without  stumbling.  At  other  times  the  child 
may  be  late  in  attempting  to  walk,  and  is  obliged  to  support 
himself  by  holding  on  to  the  nearest  article  of  furniture.  The 
parents  are  not  readily  alarmed  at  the  inability  of  the  child  to 
walk,  inasmuch  as  the  limbs  appear  to  be  so  well  developed. 
When  standing  or  walking  the  feet  are  widely  separated  from  one 
another,  and  when  they  are  made  to  approach  each  other  walking 
is  rendered  difficult,  and  the  child  may  fall.  In  walking,  the 
body  is  inclined  from  side  to  side,  so  that  the  gait  resembles  the 
waddling  of  a  duck.  When  the  feet  are  kept  widely  apart  the 
centre  of  gravity  at  each  step  must  be  carried  well  over  to  the 
side  of  the  active  leg,  in  order  that  the  line  of  gravity  may  pass 
through  the  centre  of  tbe  arch  of  the  foot  planted  on  the  ground. 
Duchenne  thought  that  the  oscillation  of  the  body  in  walking 
depended  upon  weakness  of  the  gluteus  medius.     But  in  the 

case  of  Charlotte  A ,  already  described  (§  425),  the  gluteus 

medius  on  both  sides  was  paralysed,  yet  instead  of  the  waddling 
gait  so  characteristic  of  pseudo-hypertrophic  paralysis,  the  head 
and  body  were  moved  forwards  during  locomotion  in  a  straight 
line,  without  the  normal  lateral  inclination  of  them  being 
observed. 

In  several  cases  of  pseudo-hypertrophic  paralysis  which  I 
have  examined  with  reference  to  this  point,  on  placing  one  of 
my  hands  on  each  side  of  the  pelvis  immediately  above  the . 
trochanters,  the  gluteus  medius  on  the  side  of  the  active  leg 
could  be  distinctly  felt  to  contract  at  each  successive  step. 
The  patients  also,  when  lying  on  one  side,  with  legs  extended, 
are  able  to  raise  the  upper  leg  away  from  the  other,  without 
much  apparent  difficulty,  and  when  the  hand  is  placed  over 
the  gluteus  medius  during  this  movement  the  muscle  may 
be  felt  to  contract  powerfully.  In  an  advanced  case  of  the 
disease  which  I  saw  recently,  along  with  my  friend  Dr.  John 
Brown,  of  Burnley,  the  patient  could  not  stand  or  sit  erect,  yet 
when  lying  on  his  side  he  could  abduct  the  upper  leg,  and  on 
placing  my  hand  above  the  great  trochanter  of  the  femur  the 
gluteus  medius  was  felt  to  contract.  This  muscle  was,  therefore, 
not  likely  to  have  been  affected  at  an  early  period  of  the  affec- 
tion. The  oscillation  of  the  body  in  walking,  therefore,  instead 
of  being  caused  by  paralysis  of  the  gluteus  medius,  is,  in  my 


996  SYSTEM  DISEASES   OF  THE 

opinion,  mainly  effected  by  contraction  of  this  muscle.  The 
lateral  inclination  of  the  body  appears,  indeed,  to  be  rendered 
necessary  in  the  early  stage  of  the  affection  partly  by  the  legs 
being  held  widely  apart,  and  partly  by  the  inability  of  the 
patient  to  produce  dorsal  flexion  of  the  foot  so  as  to  allow  the 
passive  leg  to  swing  forward  in  locomotion. 

In  the  second  stage  of  the  disease,  when  double  talipes  equinus 
and  dorsal  curvature  are  established,  other  factors  co-operate  in 
the  production  of  the  alternate  balancings  of  the  body.  When 
talipes  equinus  is  once  formed,  the  body  at  each  successive  step 
must  be  delicately  balanced  so  that  the  line  of  gravity  will  pass 
through  the  ball  of  the  foot,  and  consequently  the  slightest  dis- 
placement of  the  centre  of  gravity  would  cause  the  patient  to  fall. 
It  is  therefore  necessary  that  at  each  step  the  body  should  be  in- 
clined well  over  to  the  side  of  the  active  leg,  and  the  patient  aids 
himself  in  balancing  the  body  on  the  ball  of  the  foot  on  the  side 
of  the  active  leg  by  moving  his  arms  about  like  a  rope  dancer. 

When  the  patient  is  laid  down  or  falls,  he  raises  himself  in  a 
characteristic  manner.  If  any  object  be  near  which  he  can 
conveniently  grasp,  such  as  a  chair  or  other  article  of  furniture, 
he  drags  himself  up  by  his  arms.  When  the  patient  has  to  get 
up  without  extraneous  aid,  he  first  raises  himself  on  his  hands 
and  feet.  In  the  first  position  which  he  assumes  the  patient's 
feet  are  planted  on  the  ground,  the  different  segments  of  the 
lower  extremities  are  slightly  flexed  upon  one  another,  the  body 
is  flexed  on  the  lower  extremities,  and  the  head  directed  down- 
wards, and  the  tips  of  the  fingers  of  both  hands  rest  on  the 
ground  a  little  in  front  of  the  toes  (Plate  III.,  1.)  The  patient 
next  raises  his  hand,  say  the  left,  and  places  it  above  the  left 
knee.  The  body  is  now  drawn  over  to  the  opposite  side  so  that 
its  weight  rests  mainly  on  the  right  leg,  by  one  vigorous  push  of 
the  left  arm  the  left  knee-joint  is  thrust  backwards,  and  the  leg 
and  thigh  are  thus  extended  one  upon  another,  while  the  body 
is  at  the  same  time  thrust  upwards.  The  feeble  extensors  of  the 
body  on  the  thigh  are  now  brought  into  action,  and  the  trunk  is 
partly  raised  upwards  by  their  contraction,  and  partly  pushed 
upwards  by  the  left  upper  extremity,  while  the  right  may  not 
require  to  be  placed  over  the  right  knee  in  the  early  stage  of 
the  affection. 


^B^Iilj^iuMj^i^^j 


SPINAL   CORD   AND  MEDULLA   OBLONGATA.  997 

But  even  in  the  early  stage  of  the  disease  the  action  of  the 
extensors  of  the  body  on  the  thighs  is  greatly  aided  by  the 
abductors  of  the  thighs,  and  the  patient  may  be  observed  to 
elevate  the  trunk  by  a  kind  of  rotatory  movement,  the  body 
being  drawn  first  to  the  one  side  and  then  to  the  other. 

The  following  case  has  afforded  me  an  opportunity  of  studying 
the  different  movements  which  are  made  in  the  act  of  attaining 
the  erect  posture,  inasmuch  as  these  are  slowly  performed  ;  and 
as  the  case  is  of  interest  in  other  respects,  I  shall  describe  the 
symptoms  in  detail.  I  have  received  valuable  assistance  from 
Dr.  A.  H.  Young  in  describing  the  different  groups  of  muscles 
which  are  brought  into  action  by  the  patient  in  attaining  the 
erect  posture. 

Case  VII. — Peter  P ,  forty-five  years  of  age,  was  admitted  to  the  Royal 

Infirmary,  Mancliester,  February  12th,  1880.  He  was  quite  healthy  until  ten 
years  of  age,  when  he  had  an  attack  of  typhoid  fever.  Dui-ing  the  attack  of 
fever  he  suffered  from  bed-sores,  and  his  recovery  was  slow  and  protracted. 
Subsequent  to  this  period  he  could  ascend  a  stair  without  difficulty,  and 
could  carry  weights  like  other  people.  He  thinks,  however,  that  his  mode 
of  walking  was  peculiar,  and  that  he  was  weak  on  his  legs.  He  could  not 
join  in  games  which  required  active  exercise,  as  running,  and  the  other  boys 
at  school  amused  themselves -by  pushing  against  him  and  throwing  him 
down.  At  fifteen  years  of  age  he  was  apprenticed  to  a  joiner,  and  was  then 
able  to  ascend  a  ladder  and  perform  the  ordinary  work.  It  was  not,  indeed, 
until  he  was  thirty  years  of  age  that  his  present  symptoms  began  to  attract 
attention.  At  this  time  his  master  observed  that  he  was  unable  to  get 
through  his  work  like  the  other  men,  and  consequently  he  was  the  first  to 
be  discharged  when  work  was  scarce.  The  first  symptom  which  attracted 
his  attention  was  that  he  was  unable  to  ascend  a  stair  without  placing  his 
hand  on  his  knee,  while  holding  on  to  the  banister  with  the  other  hand. 
From  that  time  up  to  the  present,  a  period  of  thirteen  years,  he  has  become 
gradually  and  slowly  worse.  He  was  married  thirteen  years  ago,  and  has 
three  childi'en,  all  of  whom  are  healthy. 

Present  Condition. — The  patient  seems  fairly  well  nourished  and  healthy. 
There  is  a  cicatrix  two  inches  in  diameter  on  the  prominent  part  of  the 
sacrum,  and  a  smaller  one  over  the  great  trochanter  of  the  femur,  on  each 
side,  these  being  left  by  the  bed-sores  from  which  he  suffered  when  iU  of 
typhoid  fever. 

As  the  patient  stands  on  the  floor  in  the  erect  posture  his  feet  are 
4  J  inches  apart  at  the  heels  and  ten  inches  at  the  toes.  The  heels  scarcely 
touch  the  ground  ;  when  he  stands  on  his  naked  feet  a  piece  of  cardboard 
can  be  readily  passed  between  the  heels  and  the  floor.  When  he  raises  his 
foot  off"  the  ground  it  assumes  the  position  of  talipes  equino-varus,  and  he. 


998  SYSTEM  DISEASES   OF   THE 

cannot  produce  dorsal  flexion  of  the  foot,  but  there  is  no  deformity  of  the 
toes.  When  the  patient  is  standing  the  muscles  of  the  calf  are  hard,  tense, 
comparatively  large,  and  weU  formed.  The  muscles  of  the  thigh  are  small, 
soft,  and  flabby,  so  that  the  comparatively  slender  thighs  offer  a  striking 
contrast  to  the  large  and  well-formed  calves.  The  buttocks  are  somewhat 
flattened,  and  fibrillary  movements  are  observed  in  the  erector  spinas  and 
the  muscles  of  the  back  of  the  thigh.  The  scapular  muscles  are  unaffected, 
the  deltoids  are  prominent,  and  act  with  great  energy  on  voluntary  effort. 
The  pectoral  muscles  are  decidedly  atrophied,  and  the  triceps,  biceps,  and 
the  coraco-brachiahs  are  wasted  to  so  marked  a  degree  that  the  slenderness 
of  the  arm  offers  a  strong  contrast  to  the  full  and  rounded  shoulder  caused 
by  the  pronainence  of  the  deltoid.  The  muscles  of  the  forearm  are  not 
atrophied,  and  they  stand  out  prominently  under  the  skin,  and  feel  hard 
and  tense  when  the  patient  grasps  anything  strongly,  yet  his  grasp  is 
remarkably  feeble.  Dr.  Leech,  who  has  made  a  microscopic  examination 
of  portions  of  these  muscles  withdrawn  by  his  trocar,  assures  me  that  they 
exhibit  morbid  changes,  but  he  is  unable  to  say  that  they  are  the  same  as 
those  which  characterise  pseudo-hypertrophy  of  muscle. 

The  following  measurements  were  taken  :  Height  5ft.  7in.,  circumference 
of  the  chest  32in.,  abdomen  Sljin.,  upper  part  of  each  thigh  16|in.,  middle 
of  each  thigh  13in.,  each  calf  13 Jin.,  upper  arm  7jin.,  forearm  9|in.  The 
circiunference  of  the  calf  exceeds  that  of  the  middle  of  the  thigh,  while 
the  circumference  of  the  forearm  greatly  exceeds  that  of  the  upper  arm. 
While  standing  the  pelvis  is  inclined  well  forwards,  his  abdomen  is  some- 
what protuberant  ;  while  the  upper  part  of  the  body  is  dragged  backwards, 
so  that  a  deep  curve,  with  its  concavity  directed  backwards,  is  formed  in 
the  lumbo-dorsal  region.  A  plumb-line,  let  fall  from  the  most  prominent 
of  the  spinous  processes  of  the  upper  dorsal  vertebrae,  falls  three  inches 
behind  the  sacrum. 

Walking. — The  gait  of  the  patient  is  peculiar  and  characteristic ;  the 
body  is  alternately  drawn  from  side  to  side,  giving  to  the  walk  a  duck-hke 
or  waddhng  movement.  The  patient,  as  already  remarked,  can  neither 
place  the  two  heels  firmly  on  the  ground  at  the  same  time,  nor  elevate  the 
toes  by  producing  dorsal  flexion  of  the  foot,  and  consequently  the  passive 
leg  cannot  swing  forwards  with  the  normal  pendiilum  movement. 

The  difl&culty  of  moving  the  passive  leg  forwards  is,  indeed,  increased 
by  the  fact  that  the  predominant  action  of  the  muscles  of  the  calf  extends 
the  foot  and  the  leg  when  once  it  is  raised  off  the  ground,  so  that  the  limb 
is  lengthened  instead  of  being  shortened  by  dorsal  flexion  of  the  foot,  as  in 
normal  locomotion.  Under  these  circumstances  the  toes  of  the  passive  leg 
are  made  to  clear  the  ground  by  a  different  mechanism  from  that  which 
obtains  in  health.  The  feet  are,  as  already  described,  held  widely  apart^ 
and  when  the  passive  leg,  say  the  right,  is  to  be  moved  forwards  the  body 
is  dragged  well  over  to  the  left.  This  movement  is  mainly  effected  by  the 
abductors  of  the  thigh  on  the  side  of  the  active  leg,  and  the  gluteus  medius 
on  that  side  is  felt  strongly  contracted  on  placing  the  hand  over  it.     But 


SPINAL  CORD   AND  MEDULLA  OBLONGATA.  999 

the  centre  of  gravity  is  not  only  drawn  over  to  tlie  side  of  the  active  leg, 
but  it  is  also  drawn  somewhat  backwards  by  the  action  of  the  gluteal  and 
probably  also  the  hamstring  muscles,  and  the  line  of  gravity  in  passing 
through  the  arch  of  the  left  foot  approaches  the  heel,  and  the  latter  is  now 
felt  to  be  firmly  planted  on  the  groimd.  During  this  double  but  combined 
movement  the  hne  of  gravity  is  in  danger  of  being  carried  too  far  to  the 
left  and  backwards,  hence  the  right  arm  is  thrown  outwards  and  forwards 
so  as  to  maintain  the  centre  of  gi'avity  as  far  to  the  right  and  forwards  as 
possible.  During  the  lateral  movement  of  the  body  towards  the  side  of 
the  active  leg  the  pelvis  on  the  side  of  the  passive  leg  is  elevated,  and  thus 
the  length  between  the  head  of  the  femur  and  ground  is  increased,  and 
during  the  backward  movement  of  the  body  the  pelvis  is  made  to  assume 
a  more  vertical  position,  so  that  the  flexors  of  the  thigh  on  the  body  can 
act  more  efficiently  on  the  passive  leg.  The  thigh  of  the  passive  leg  is  now 
flexed  on  the  body,  the  abductors  also  contracting  and  giving  to  the  thigh 
a,n  outward  inclination,  the  leg  is  slighly  flexed  on  the  thigh,  and  the  foot  is 
moved  slowly  forwards  and  outwards,  and  when  the  step  is  completed  the 
toe  comes  first  to  the  ground. 

The  forward  and  outward  projection  of  the  passive  leg  tends  to  counter- 
act the  tendency  of  the  line  of  gravity  to  pass  too  far  to  the  side  of  the 
active  leg  and  backwards.  When  the  passive  leg  is  placed  on  the  ground 
the  abductors  of  the  thigh  on  that  side  contract,  the  body  is  drawn  over  to 
the  right,  and  the  line  of  gravity  is  slowly  transferred  to  the  leg  that  was 
passive  and  which  now  in  its  turn  becomes  active. 

Attaining  the  Erect  Posture. — On  rising  from  the  recumbent  position 
the  patient  first  gets  on  his  hands  and  knees,  and  placing  his  right  foot  on 
the  ground,  he  rests  his  right  elbow  above  the  knee,  and  inclines  his  trunk 
to  the  right  so  that  the  centre  of  gravity  passes  through  the  right  foot. 
When  he  leans  well  forwards  in  this  position  and  presses  his  right  elbow 
downwards  and  backwards,  it  will  tend  to  drag  the  trunk  and  with  it  the 
right  hip-joint  forwards,  but  inasmuch  as  the  right  knee  is  at  the  same 
time  pressed  downwards  and  backwards,  any  forward  movement  of  the 
hip-joint  must  be  accompanied  by  elevation.  The  weight  of  the  trunk  is, 
therefore,  so  apphed  that  it  tends  to  drag  the  hip-joint  forwards  and 
upwards,  and  thus  to  extend  the  trunk  on  the  thighs  and  to  push  the  right 
knee-joint  downwards  and  backwards,  and  thus  to  extend  the  leg  upon  the 
thigh,  so  that  the  weight  of  the  trunk  is  so  applied  as  to  aid  the  extensors 
in  erecting  the  body. 

The  extensor  muscles  are  now  brought  into  action,  and  the  trunk  is 
slowly  elevated  to  what  I  may  call  the  second  position.  In  this  position 
the  various  segments  of  the  right  lower  extremity  are  slightly  flexed  upon 
one  another,  the  trunk  is  directed  forwards  horizontally,  and  the  right 
elbow  rests  above  the  knee,  while  the  left  thigh  is  directed  vertically 
downwards,  the  left  leg  is  incUned  downwards  and  backwards,  and  the  toe 
rests  on  the  ground  considerably  behind  the  right  foot,  while  the  left  hand 
rests  lightly  on  the  left  thigh  immediately  above  the  knee. 


]000  SYSTEM  DISEASES  OF  THE 

After  a  momentary  pause  the  patient  proceeds  to  attain  the  third  posi- 
tion. The  abductors  of  the  right  thigh  contract  and  rotate  the  pelvis  so 
that  the  left  hip-joint  is  sHghtly  elevated.  This  movement  brings  the  line 
of  gravity  well  within  the  right  foot,  and  takes  the  weight  of  the  trunk 
entirely  off  the  left  lower  extremity.  The  left  foot  is  now  drawn  forwards 
and  placed  on  the  ground  in  a  line  with  the  right  foot,  but  slightly  removed 
from  it  laterally,  while  the  left  hand  at  the  same  time  grasps  the  left  thigh 
immediately  above  the  knee.  By  a  contraction  of  the  abductors  and 
extensors  of  the  left  thigh  the  line  of  gravity  is  now  transferred  from  the 
right  to  the  left  foot,  the  right  shoulder  is  elevated,  and  the  right  hand  is 
quickly  transferred  to  the  position  previously  occupied  by  the  elbow  ;  the 
abductors  and  extensors  of  the  left  thigh  now  relax,  until  the  line  of  gravity 
passes  between  the  feet,  and  the  third  position  is  attained. 

In  this  position  the  two  sides  are  symmetrically  placed.  The  feet  are 
placed  on  the  ground  and  somewhat  removed  from  one  another,  but  the 
heels  do  not  quite  touch  the  ground  ;  the  legs  are  slightly  flexed  on  the 
feet,  the  thighs  on  the  legs,  and  the  trunk  on  the  thighs  ;  both  arms  pass 
downwards  and  backwards,  each  hand  grasping  the  thigh  of  the  corre- 
sponding side  close  above  the  knee.  When  the  patient  is  viewed  laterally, 
the  thigh,  arm,  and  trunk  are  seen  to  form  the  three  sides  of  a  triangle 
(Plate  III.,  3),  and  the  weight  of  the  trunk  applied  through  the  arms  must 
tend  to  push  both  knees  downwards  and  backwards,  while  at  the  same  time 
tending  to  elevate  the  hip-joints.  The  body  is  inclined  forwards  and 
upwards,  but  owing  to  the  deep  dorso-lmnbar  curve  the  vertical  axis  of  the 
pelvis  occupies  a  more  horizontal  position  than  might  be  expected  from  the 
upward  inclination  of  the  body.  The  line  which  joins  the  anterior  superior 
spine  of  the  ilium  and  the  head  of  the  femur  forms  nearly  a  right  angle 
with  that  which  joins  the  head  of  the  femur  and  the  centre  of  the  arch  of 
the  foot  5  and,  consequently,  were  the  gluteus  medius  and  minimus  of  both 
sides  now  to  contract,  they  would  act  mainly  as  flexors  of  the  pelvis  on  the 
thighs. 

The  patient,  after  a  little  pause  to  take  breath,  prepares  for  a  further 
elevation  of  the  body  ;  the  great  difficulty  he  has  to  encounter  is  to  erect 
the  pelvis  on  the  thighs,  while  at  the  same  time  extending  the  various 
segments  of  the  lower  extremities  upon  one  another.  By  transferring  the 
line  of  gravity  from  one  foot  to  the  other  he  takes  the  weight  of  the  body 
off  each  foot  alternately,  and  in  this  way  he  is  enabled  to  slip  by  turns 
each  hand  further  up  the  thighs  until  he  grasps  them  about  the  jimction 
of  the  middle  with  the  lower  third.  The  trunk  is  now  dragged  over  to  the 
left,  so  that  the  line  of  gravity  passes  through  the  left  foot,  and  the  right 
hand  is  removed  from  the  right  thigh  (Plate  III.,  4).  The  right  foot  is 
shuffled  outwards  and  backwards,  so  as  to  allow  the  leg  to  be  fully  extended 
on  the  thigh.  This  movement  is  performed  with  great  deliberation,  and 
after  it  is  effected  the  patient  rests  for  a  moment  as  if  to  assure  himself 
that  the  right  foot,  which  now  rests  on  its  inner  edge  considerably  behind 
and  removed  from  the  left  foot,  is  firmly  planted  so  as  not  to  slip.     The 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  1001 

final  effort  now  begins.  Apparently  by  a  combined  action  of  the  inward 
rotators  of  the  left  and  of  the  outward  rotators  of  tbe  right  thigb  the  pelvis 
is  rotated  obliquely  from  before  backwards  and  from  right  to  left.  By  this 
movement  the  right  hip-joint  is  brought  weU  forwards,  and  the  pelvis  is 
probably  also,  by  a  simultaneous  action  of  the  extensors  of  the  body  on  the 
thigh,  made  to  assume  a  more  vertical  position.  But  whatever  may  be  the 
nature  of  the  muscular  action  concerned  in  this  movement,  when  it  is 
completed  the  head  of  the  right  femur  is  placed  almost  vertically  below  the 
anterior  superior  spine  of  the  ilium,  instead  of  being  on  the  same  horizontal 
plane  with  it  as  in  the  third  position.  The  line  which  joins  the  anterior 
superior  spine  of  the  ilium  and  the  great  trochanter  now  forms  a  very 
obtuse  angle  with  that  joining  the  great  trochanter  and  the  middle  of  the 
arch  of  the  foot,  and  in  this  position  the  gluteus  minimus  and  medius  will 
act  mainly  as  extensors  of  the  pelvis  on  the  thighs.  The  great  effort  of  the 
patient  is  now  directed  to  transfer  the  line  of  gravity  from  the  left  to  the 
right  foot.  This  is  effected  by  the  trunk  being  dragged  over  in  a  diagonal 
manner  from  before  backwards  and  from  left  to  right,  partly  by  the  con- 
joined action  of  the  extensors  and  abductors  of  the  right  thigh,  and  partly 
by  the  left  shoulder  being  pushed  upwards  and  to  the  opposite  side  by 
forces  acting  upon  it  from  below  through  the  arm.  The  elevation  of  the 
left  shoulder  is  effected  by  the  extension  of  the  different  segments  of  the 
arm  upon  one  another,  and  by  the  elevation  of  the  heel  and  consequently 
of  the  knee  by  contraction  of  the  muscles  of  the  calf.  The  upward  move- 
ment of  the  left  shoulder  is  not  one  of  simple  elevation,  but  is  indeed  a 
very  complex  act.  The  left  knee  is  not  only  elevated  by  contraction  of  the 
muscles  of  the  calf,  but  a  strong  contraction  of  the  adductors  of  the  thigh 
prevents  it  from  being  thrust  out  laterally.  The  inward  rotators  of  the 
left  arm  (the  latissimus  dorsi,  teres  major  and  minor,  and  infraspinatus), 
and  the  abductors  of  the  arm,  especially  the  posterior  third  of  the  deltoid, 
enter  into  strong  contraction.  The  tendency  of  the  combined  action  of 
these  muscles  is,  the  arm  being  fixed  by  the  hand  gras]3ing  the  knee,  to 
thrust  the  left  shoulder  to  the  opposite  side,  and  to  rotate  the  body,  so  that 
the  left  shoulder  is  pushed  forwards  in  advance  of  the  right  one.  We  have 
already  seen  that  the  pelvis  was  rotated  in  such  a  way  that  the  right  was 
placed  in  advance  of  the  left  hip-joint,  and  now  the  left  is  pushed  forwards 
in  advance  of  the  right  shoulder,  and  consequently  the  upper  part  of  the 
body  is  being  rotated  in  the  opposite  direction  to  the  lower  part  ;  or,  in 
other  words,  the  pelvis  is  being  rotated  from  right  to  left  through  the  hip- 
joints,  and  from  left  to  right  through  the  vertebral  column,  the  power  in 
the  latter  case  being  applied  on  a  level  with  the  brim  of  the  pelvis.  If  the 
forces  which  tend  to  rotate  the  pelvis  from  right  to  left,  and  those  which 
tend  to  rotate  it  from  left  to  right  were  applied  on  the  same  level,  they 
would  tend  to  neutraUse  one  another,  and  the  pelvis  would  remain  more  or 
less  fixed.  But,  inasmuch  as  the  forces  which  rotate  the  peMs  from  right 
to  left  are  apphed  through  the  hip-joints,  and  those  which  tend  to  rotate  it 
from  left  to  right  through  the  vertebral  column,  the  consequence  is  that  the 


1002  SYSTEM  DISEASES   OF  THE 

former  will  tend  to  push  the  head  of  the  right  femur  forwards,  while  the 
latter  will  tend  to  carry  the  brim  of  the  right  ilium  backwards.  It  will 
be  thus  seen  that  the  forward  rotation  of  the  left  sboxilder  will  tend  to 
carry  the  anterior  superior  spine  of  the  right  ilium  backwards,  and 
therefore  assists  the  action  of  the  gluteus  medius  and  minimus  of  the 
right  side  as  extensors  of  the  body  on  the  thigh.  It  may,  indeed,  be 
said  that  the  double  rotation  just  described  twists  or  screws  the  pelvis 
into  a  more  or  less  erect  position  with  reference  to  the  right  lower 
extremity,  around  the  hip-joint  of  which  all  the  movements  of  the  body  at 
present  centre. 

As  the  Une  of  gravity  approaches  the  right  foot,  the  left  lower  extremity 
is  becoming  more  and  more  inclined  forwards  and  outwards,  its  different 
segments  become  extended  upon  one  another,  and  the  toe  rests  on  the 
ground.  When  once  the  hne  of  gravity  passes  through  the  right  foot,  the 
extensors  and  abductors  of  the  right  thigh  relax  somewhat,  while  those  of 
the  left  now  suddenly  contract ;  the  pelvis  is  rotated  once  more  in  such  a 
way  that  the  head  of  the  left  femur  is  brought  forwards  under  the  pelvis. 
During  this  movement  the  left  hand  is  removed  from  the  thigh,  the 
muscles  of  the  calf  relax,  the  heel  comes  to  the  ground,  and  the  line  of 
gravity  is  for  a  moment  transferred  to  the  left  foot,  but  immediately  after- 
wards the  weight  of  the  body  is  borne  by  both  feet,  the  line  of  gravity 
falling  between  them,  and  the  erect  posture  is  attained. 

When  the  patient  reclines  on  one  side  he  can  raise  the  uppermost  leg 
away  from  the  other  with  a  considerable  degree  of  force,  and  during  this 
action  the  gluteus  medius  can  be  felt  strongly  contracted. 

When  sitting  he  can  cross  one  leg  over  the  other  readily,  abduct  and 
adduct  his  legs  with  considerable  force  against  a  resisting  object,  but  he 
can  only  produce  dorsal  flexion  of  the  foot  to  a  slight  extent. 

Owing  to  the  feebleness  of  the  gluteus  maximus,  the  patient 
experiences  great  difficulty  in  getting  up  steps,  and  the  manner 
in  which  he  ascends  a  stair  is  as  characteristic  as  that  in  which 
he  attains  the  erect  posture.  He  lays  hold  of  the  railing  with 
one  hand,  say  the  right,  and  by  the  contraction  of  the  muscles  of 
the  right  upper  extremity  he  drags  his  body  upwards  at  each 
step.  The  right  arm  is,  however,  assisted  by  the  left.  The  left 
hand  is  planted  above  the  left  knee,  and  each  time  the  left  leg 
is  raised  a  step  the  body  is  thrust  upwards  by  the  various 
segments  of  the  left  arm  being  extended  upon  one  another. 

One  of  the  most  constant  symptoms  of  the  disease  is  the 
existence,  during  standing  or  walking,  of  a  remarkable  curvature 
of  the  spine  in  the  lumbo-sacral  region.  The  shoulders  and 
upper  part  of  the  vertebral  column  are  carried  backwards,  so  that 
a  plumb-line  let  fall  from  the  most  prominent  spinous  process  of 


SPINAL   CORD   AND  MEDULLA  OBLONGATA.  1003 

the  vertebrae  falls  behind  the  sacrum.  I  have,  however,  observed 
an  undoubted  example  of  the  disease  in  which  the  plumb-line 
did  not  clear  the  sacrum.  Duchenne  attributes  this  incurvation 
to  weakness  of  the  erector  muscles  of  the  spine ;  but,  as  pointed 
out  by  Dr.  Gowers,  weakness  of  the  extensors  of  the  pelvis  on  the 
thighs  contributes  to  the  formation  of  the  lordosis.  Weakness 
of  the  extensors  allows  the  pelvis,  and  with  it  the  lowest  lumbar 
vertebrae,  to  incline  forwards  in  the  erect  posture,  and  a  com- 
pensatory backward  inclination  of  the  dorsal  spine  is  necessary  in 
order  to  keep  the  centre  of  gravity  in  the  normal  position. 

Another  important  feature  of  the  disease  is  that  the  patient 
has  a  difficulty  in  bringing  his  heels  to  the  ground ;  and,  as  the 
case  advances,  a  permanent  condition  of  talipes  equinus,  or 
equino-varus,  is  established.  The  foot  becomes  more  hollow  from 
increase  of  the  plantar  arch,  while  paralysis  of  the  interossei 
causes  the  first  phalanges  to  be  maintained  in  a  state  of  exag- 
gerated extension  on  the  metatarsal  bones,  and  the  two  distal 
phalanges  to  be  flexed,  so  that  the  toes  assume  the  peculiar  claw- 
like appearance,  which  Duchenne  has  called  griffe  des  orteils. 

The  apparent  hypertrophy  of  the  muscles  generally  begins  by 
enlargement  of  one  calf,  the  other  also  becoming  affected  before 
very  long.  But  although  this  is  the  usual  mode  of  invasion,  the 
muscular  enlargement  sometimes  begins  in  the  muscles  of  the 
upper  extremities,  as  in  a  case  related  by  Duchenne,  where  the 
deltoids  had  begun  to  enlarge  many  months  before  the  gastro- 
cnemii.  The  gluteal  muscles  become  affected  soon  after  those 
of  the  calf,  and  then  the  disease  extends  in  succession  to  the 
lumbo-spinal  muscles  and  to  some  of  the  muscles  of  the  thigh, 
trunk,  and  upper  extremities.  Of  the  muscles  of  the  upper 
extremities  the  deltoids  are  usually  the  first  to  suffer.  In  one 
case  related  by  Duchenne  the  apparent  hypertrophy  had  become 
so  general  that,  with  the  exception  of  the  pectoral  muscles,  the 
latissimus  dorsi,  and  the  sterno-mastoids,  all  the  muscles  of  the 
limbs,  trunk,  and  even  those  of  the  face,  especially  the  tem- 
porals, were  successively  invaded.  In  a  case  related  by  Weir 
Mitchell^  not  only  the  muscles  of  the  face,  but  even  those  of 
the  tongue,  were  hypertrophied. 

1  Mitchell  (S.  Weir).  Photographic  Eeview,  Oct.,  1871 ;  and  Boston  Medical 
and  Surgical  Journal,  1879,  p.  247. 


1004  SYSTEM  DISEASES  OF  THE 

The  affected  muscles  may  attain  an  enormous  volume,  and 
stand  out  so  prominently  under  the  skin  that  Duchenne  uses 
the  term  "hernial  protrusions"  to  describe  their  appearance. 
The  muscles  also  feel  hard  and  resisting  to  the  touch,  so  that 
the  whole  appearance  of  the  child  often  suggests  the  idea  of 
Herculean  strength  instead  of  the  great  feebleness  which  in 
reality  exists.  But  even  amidst  all  this  apparent  development 
of  muscular  power  there  are  not  wanting  visible  indications  of 
the  real  nature  of  the  malady.  Some  of  the  muscles  are  always 
found  atrophied,  their  wasted  condition  contrasting  strongly 
with  the  excessive  size  of  the  others.  Even  in  the  case  related 
by  Duchenne,  where  the  child  looked  like  a  young  Hercules, 
the  pectorals  and  latissimus  dorsi  were  atrophied.  In  the 
majority  of  cases  the  muscles  of  the  calves  and  buttocks,  and 
probably  also  the  deltoids,  are  enlarged,  while  the  remaining 
muscles  of  the  arm,  forearm,  shoulders,  and  trunk  are  atrophied ; 
so  that  the  slenderness  of  the  upper  part  of  the  body  offers  a 
strong  contrast  to  the  abnormal  development  of  the  inferior 
extremities.  We  see,  therefore,  that  all  the  paralysed  muscles 
do  not  undergo  augmentation  of  bulk ;  in  fact,  atrophy  of 
some  of  the  muscles  is  a  constant  symptom  of  the  disease. 
Another  circumstance  worth  noting  is  that  the  degree  of  para- 
lysis has  no  direct  relation  to  the  amount  of  hypertrophy. 
This  is  well  illustrated  in  the  leg  where  the  action  of  the 
extensors  of  the  foot,  although  these  are  much  enlarged,  pre- 
dominates over  that  of  the  flexors,  as  evinced  by  the  elevation 
of  the  heel. 

The  disease  now  becomes  more  or  less  stationary  for  two  or 
three  years,  and  sometimes  for  a  much  longer  period,  and  as 
the  general  health  is  good  and  the  muscular  development 
apparently  very  powerful,  the  parents  cannot  believe  that  the 
affection  is  incurable.  This  illusion  is,  however,  after  a  time 
destined  to  be  dispelled.  The  feebleness  of  the  lower  extre- 
mities gradually  increases,  so  that  the  child  cannot  maintain 
the  erect  posture,  while  the  muscles  of  the  superior  extremities 
also  become  both  paralysed  and  atrophied ;  and  even  the  hyper- 
trophied  limbs  begin  to  waste,  and  to  diminish  rapidly  in  size. 
The  patient,  now  arrived  at  adolescence,  may  live  on  for  several 
years  in  a  condition  of  almost  complete  paralysis,  until  finally 


SPINAL   CORD  AND  MEDULLA   OBLONGATA.  1005 

death  takes  place  from  exhaustion,  implication  of  the  respiratory 
muscles,  or  more  usually  from  some  intercurrent  affection. 

There  are  still  some  minor  features  of  the  disease  which 
deserve  attention.  The  statements  of  different  observers,  with 
respect  to  the  electro-muscular  contractility,  are  somewhat  con- 
tradictory. Except  in  the  very  early  stages  of  the  disease,  the 
faradic  contractility  is  diminished,  while  the  galvanic  contrac- 
tility may  be  normal  or  increased.  In  the  second  stage  of  the 
disease  the  quadriceps  tendon-reflex  is  completely  abolished. 

Very  frequently  the  skin  over  the  affected  parts  presents  a 
peculiar  mottled  appearance,  the  colour  varying  in  different 
cases,  and  in  the  same  case  according  to  the  degree  of  exposure. 
Sometimes  it  is  described  as  of  a  roseate  hue,  again  as  bright 
red,  and  at  other  times  as  consisting  of  patches  of  purplish 
colour  alternating  with  white.  All  of  these  phenomena,  how- 
ever, indicate  capillary  congestion,  the  result  of  vaso-motor  dis- 
turbance. This  supposition  is  still  further  strengthened  by  the 
fact  that  the  superficial  temperature  of  the  inferior  extremities 
is  frequently  higher  than  that  of  the  trunk. 

This  disease  is  often  associated  with  a  certain  amount  of 
mental  incapacity.  In  several  instances  the  subjects  of  it  have 
been  noticed  to  be  slow  in  acquiring  the  power  of  speech,  others 
are  described  as  being  obtuse  in  intelligence,  and  a  considerable 
number  have  been  idiots.  The  disease  is  not  accompanied  by 
any  suffering,  there  is  no  alteration  of  sensibility,  and  the  func- 
tions of  the  bladder  and  rectum  are  not  interfered  with,  while 
the  general  health  is  not  much  affected  until  near  the  terminal 
period  of  the  affection. 

§  446.  Course  and  Duration.— 1l\iq  disease  is  essentially 
chronic.  It  begins  without  fever  or  marked  derangement  of 
the  functions  of  digestion,  respiration,  or  circulation.  As  already 
stated,  it  consists  of  a  first  stage  in  which  there  is  progressive 
enfeeblement  of  the  lower  extremities,  saddle-back,  and  waddling 
gait.  This  stage  may  last  a  few  weeks,  months,  or  even  a  year 
before  the  commencement  of  the  next  stage.  The  second  period 
is  characterised  by  apparent  hypertrophy  of  a  certain  number  of 
muscles,  usually  beginning  in  those  of  the  calf,  and  extending 
gradually  to  other  muscles  of  the  trunk  and  upper  extremities. 


1006  SYSTEM  DISEASES  OF  THE 

Increase  in  the  volume  of  some  muscles  is  always  accompanied 
by  atrophy  of  others.  This  stage  of  muscular  hypertrophy  con- 
tinues to  increase  progressively,  and  attains  its  maximum  in 
degree  and  extent  about  eighteen  months  from  the  beginning 
of  the  second  stage  of  the  disease ;  the  symptoms  then  remain 
stationary  for  two,  or  three,  and  sometimes  for  many  years. 

The  third  stage  of  the  disease  is  now  ushered  in  by  a  still 
further  enfeeblement  of  the  muscles  already  affected,  and  by 
the  extension  of  the  paralysis  to  the  superior  extremities.  Abduc- 
tion and  elevation  of  the  arm  is  at  first  rendered  difficult,  then 
impossible,  and  by-and-by  the  paralysis  gradually  implicates 
the  other  movements  of  the  arm. 

The  child,  now  probably  arrived  at  the  age  of  puberty,  enters 
upon  the  last  stage  of  the  disease.  The  slight  power  of  move- 
ment of  which  he  was  capable  during  the  previous  period 
becomes  gradually  lost,  so  that  he  can  only  sit  in  a  chair  or 
recline  on  a  couch.  The  patient  may  continue  to  live  for  a  long 
time  in  this  condition,  but  eventually  death  supervenes  from 
exhaustion  or  some  intercurrent  malady. 

§  447.  Diagnosis. — When  the  disease  is  thoroughly  estab- 
lished there  can  scarcely  be  a  possibility  of  mistaking  it  for 
any  other  affection.  The  diseases  which  are  most  nearly  related 
to  it  are  infantile  paralysis  and  progressive  muscular  atrophy  in 
the  infant.  True  muscular  hypertrophy  may  also  be  mistaken 
for  the  disease,  and  a  likely  condition  to  be  confounded  with  it 
is  a  late  development  of  the  power  of  muscular  co-ordination 
and  walking  in  children,  especially  when  combined  with  a 
cerebral  lesion,  as  in  cases  of  idiocy. 

The  invasion  of  infantile  paralysis  is  sudden  and  accompanied 
with  fever,  and  the  distribution  of  the  paralysis  is  totally  different 
from  that  of  the  pseudo-hypertrophic  variety.  Sometimes  the 
paralysis  is  limited  to  a  few  muscles  or  to  an  entire  limb,  at 
other  times  it  is  hemiplegic,  crossed,  paraplegic,  or  general. 
The  muscles  which  are  at  least  injured  recover  completely,  while 
others  atrophy,  and  in  the  latter  there  is  very  early  and  decided 
diminution  of  electro-muscular  contractility. 

Progressive  muscular  atrophy  in  the  child  usually  begins 
between  the  age  of  five  and  seven.     Some  of  the  facial  muscles. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  1007 

principally  the  orbicularis  oris  and  zygomatici,  become  atrophied. 
After  a  stationary  period  of  some  years  the  atrophy  extends 
successively  to  the  muscles  of  the  upper  limbs  and  trunk,  and 
the  lower  extremities  are  not  affected  until  a  more  advanced 
period.  The  muscles  are  invaded  irregularly,  and  as  the  degree 
of  paralysis  is  always  proportional  to  the  amount  of  atrophy  this 
gives  rise  to  various  deformities  of  the  trunk  and  limbs.  When 
the  atrophy  attacks  the  extensor  muscles  of  the  trunk  and 
some  of  the  muscular  groups  of  the  lower  extremities,  as  in  the 
case  of  Charlotte  A.  (Case  VI.),  already  described,  progressive 
muscular  atrophy  is  by  no  means  easy  to  distinguish  from 
pseudo-hypertrophic  paralysis. 

In  making  a  diagnosis,  the  main  reliance  must  then  be 
placed  on  the  history  of  the  case,  the  progress  of  the  symptoms, 
and  a  microscopic  examination  of  portions  of  the  muscles  of  the 
calf  withdrawn  by  the  trocar. 

Simple  muscular  hypertrophy  may  be  distinguished  from 
pseudo-hypertrophic  paralysis  by  the  history  of  the  case,  the 
absence  of  paralysis  and  of  the  special  symptoms  of  the  latter 
disease,  and  if  necessary  by  a  microscopic  examination  of  the 
muscle. 

In  late  development  of  the  muscular  co-ordination  in  children 
the  feet  are  not  planted  widely  apart,  and  there  is  no  saddle- 
back or  waddling  walk.  When  want  of  co-ordination  is  com- 
bined with  idiocy  there  is  a  flow  of  saliva  from  the  half-open 
mouth,  and  the  tendon-reactions  are  generally  exaggerated  in 
the  lower  extremities. 

§  448.  Morbid  Anatomy. — The  first  examination  of  the  con- 
dition of  the  muscles  in  this  disease  was  made  in  Germany  by 
Griesenger  and  Billroth,  who  excised  in  a  young  living  subject 
a  portion  of  the  left  deltoid  which  was  completely  paralysed 
and  hypertrophied.  Duchenne,  however,  not  liking  to  undertake 
such  a  serious  operation,  invented  a  small  instrument,  which  he 
called  his  "  Emporte  piece  histologique,"  and  which  enabled  him 
to  obtain  minute  portions  of  muscular  tissue  from  the  living 
subject.  A  modification  of  this  instrument,  first  proposed  by 
Dr.  Ord,^  and  made  by  Hawksley,  London,  is  generally  used  in 

lOrd.    Med..Chir.  Transac.    Vol.  LVIL,  1874. 


1008  SYSTEM  DISEASES  OF  THE 

this  country  for  the  purpose.  But  after  repeatedly  using  Dr. 
Ord's  trocar  in  various  diseases,  I  am  quite  satisfied  that  the 
relations  which  the  different  elements  of  the  diseased  muscle 
bear  to  one  another  are  not  always  accurately  represented  by 
the  fragment  of  tissue  withdrawn  by  the  instrument.  Charcot^ 
indeed  suggests  that  Duchenne's  instrument  will  withdraw  islets 
of  connective  tissue,  inasmuch  as  it  will  seize  the  fat  cells  with 
greater  difficulty;  and,  judging  from  my  experience  of  Dr.  Ord's 
trocar,  the  objection  is  valid. 

The  happy  idea  occurred  to  Dr.  Leech  that  an  instrument 
might  be  constructed  which  would  withdraw  a  portion  of  the 
muscle  by  cutting  instead  of  by  tearing;  and  Hawksley  has 
made  one  at  his  suggestion,  which  answers  the  purpose  admi- 
rably. The  first  muscular  change  which  takes  place  in  this 
disease  consists  of  an  increase  of  the  connective  tissue  which 
separates  the  muscular  bundles  from  one  another,  so  that  the 
sheaths  of  the  muscular  bundles  become  greatly  thickened. 
There  is  also  a  corresponding  increase  of  the  connective  tissue 
which  passes  between  the  fibres  themselves.  The  comparatively 
thick  masses  of  tissue  which  now  separate  the  fibres  from  one 
another  consist  of  fibres  arranged  parallel  to  the  long  axes  of  the 
muscular  bundles,  mixed  with  a  considerable  number  of  em- 
bryonic cells.  In  this  early  stage  the  muscular  fibres  themselves 
do  not  appear  to  undergo  any  very  manifest  changes,  except  that, 
according  to  Duchenne,  their  transverse  striation  becomes  fainter, 
while  the  longitudinal  striation  becomes  more  marked.  The 
transverse  striation  is,  however,  generally  quite  distinct  until  a 
late  period  of  the  disease.  Duchenne  regarded  the  proliferation 
of  the  connective  tissue  as  the  chief  cause  of  the  increased  size 
of  the  muscle;  hence  he  called  the  disease  "paralysie  nfiyo- 
scMrosique;"  but  other  authors  believe  that  the  muscle  does  not 
increase  much  in  volume  until  the  second  stage  of  the  change 
occurs.  This  stage  consists  of  the  development  of  fat  cells  in  the 
connective  tissue  and  also  in  the  newly-formed  fibrous  tissue, 
whereby  the  muscular  fibres  become  widely  separated  from  one 
another.  The  muscular  fibres  now  become  atrophied  and  begin 
to  disappear.     They  become  narrower,  and  indeed  a  single  fibre 

»  Charcot.  LeQons  sur  lea  maladies  de  la  aysteme  nerveux.  2^  Edit.,  Tome  IL, 
1877,  p.  447. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  1009 

varies  in  diameter  at  different  points  in  its  length.  The  trans- 
verse striation  may  sometimes  disappear  in  the  narrower  fibres, 
and  be  replaced  by  granules  distributed  uniformly  through  them. 
Much  of  the  fibrous  tissue  surrounding  the  fibres  contains  oat- 
shaped  nuclei,  which  are  supposed  by  some  to  be  derived  from 
the  empty  sheaths  of  muscular  fibres  (Clarke,  Gowers).  After  a 
time  both  the  muscular  fibres  and  the  newly -formed  fibroid  tissue 
completely  disappear,  and  the  entire  muscle  is  represented  by  fat 
cells  like  those  of  an  ordinary  lipoma.  The  fat  may  subsequently 
become  absorbed,  and  connective  tissue,  with  perhaps  a  few 
traces  of  muscular  fibres,  is  all  that  is  left. 

Condition  of  the  Nervous  System. — The  brain  and  spinal  cord 
have  been  examined  in  several  patients  who  died  from  this 
disease,  but  the  examinations  possess  no  real  value  except  in 
two  or  three  instances.  Even  in  the  case  reported  by  Eulenburg, 
where  the  cord  was  examined  with  great  care  by  such  a  com- 
petent observer  as  Cohnheim,^  it  has  been  justly  objected  by 
Charcot  that  delicate  lesions  like  atrophy  of  the  motor  cells 
might  escape  detection,  inasmuch  as  the  cord  was  examined  in 
the  fresh  condition,  or  only  after  imperfect  hardening.  If  this 
objection  be  valid,  when  urged  against  an  examination  con- 
ducted by  Cohnheim,  how  much  more  true  does  it  become  when 
either  no  microscopic  examination  or  only  a  very  imperfect  one 
was  made.  M.  Barth^  examined  the  cord  in  the  case  of  a  man 
forty-four  years  old,  who  suffered  from  muscular  pseudo-hyper- 
trophy, and  found  partial  degeneration  of  the  antero-lateral 
columns,  and  diminution  of  the  number  of  ganglion  cells  in 
the  anterior  horns  of  the  cord.  Charcot,  however,  justly  points 
out  that  the  clinical  characters  of  this  case  were  more  like  amyo- 
trophic lateral  sclerosis  than  pseudo-hypertrophic  paralysis. 

The  most  important  case  hitherto  examined  is  the  one  reported 
by  Drs.  Lockhart  Clarke  and  Gowers,'  in  which  "varied  and 
extensive"  lesions  of  the  cord  were  found.  These  lesions  were 
so  numerous  that  only  the  most  important  of  them  can  be  men- 

*  Eulenburg  and  Cohnheim.  Verhandlungen  der  Berliner  med.  Gesellschaft. 
1866.    p.  191. 

'^  Barth  (O.).  "  Beitrage  zur  Kenntniss  der  Atrophia  Musculorum  lipomatosa." 
Arch,  der  Heilkunde,  Bd.  XII.,  1871,  p.  121, 

^  Clarke  and  Gowers.  "On  a  case  of  pseudo-hypertrophic  muscular  paralysis." 
Medico-Chir.  Transactions,  Vol,  LVII.,  1874,  p.  247. 

VOL.  L  MMM 


1010  SYSTEM  DISEASES  OF  THE 

tioned  here.  The  changes  began  on  a  level  with  the  origin  of 
the  second  cervical  pair  of  nerves,  and  consisted  of  "  disintegra- 
tion of  the  lateral  grey  network  which  is  so  conspicuous  in  the 
region  between  the  caput  cornu  posterioris  and  the  tractus  inter- 
medio-lateralis,  and  through  which  the  spinal  accessory  nerve 
makes  its  way  into  that  tract."  "  One-half  of  the  anterior  white 
commissure  was  entirely  destroyed."  In  the  lower  part  of  the 
cervical  region  there  was  disintegration  of  some  of  the  "posterior 
nerve  roots  near  the  entrance  into  the  caput  cornu  posterioris," 
and  both  the  lateral  and  posterior  white  columns  were  in  many 
sections  damaged  by  sclerosis.  In  the  upper  portion  of  the 
dorsal  region  "  the  changes  were  less  frequent  and  extensive,  but 
here  and  there  the  anterior  white  commissure  was  partially 
destroyed."  The  lesions  were  "  most  extensive  and  striking  "  at 
the  lower  part  of  the  dorsal  region  and  the  commencement  of  the 
lumbar  enlargement.  The  central  and  lateral  parts  of  the  grey 
substance  on  each  side  were  severely  damaged  by  softening  and 
disintegration.  In  the  middle  part  of  the  lumbar  enlargement 
the  lesions  were  less  serious,  but  in  the  lower  portions  and  in  the 
conus  medullaris  the  lesions  of  the  grey  substance  were  again 
more  extensive  and  severe.  "  The  central  part  of  the  anterior 
Cornu  and  the  outer  part  of  the  cervix  cornu  posterioris  were 
very  much  damaged  by  continuous  disintegration."  The  large 
nerve  cells  in  the  anterior  cornua  were  much  diminished  in 
number,  and  the  few  remaining  cells  were  atrophied  and  con- 
tained an  excess  of  pigment. 

A  case  of  this  disease,  in  a  boy  aged  fourteen  years  at  the 
time  of  death,  has  been  recorded  by  Dr.  David  Drummond,^ 
in  which  decided  changes  were  found  in  the  spinal  cord.  The 
principal  alterations  met  with  are  briefly  described  as  "disin- 
tegration in  the  lateral  grey  network  of  fibres,  least  marked  on 
the  left  side,  and  in  the  lumbar  enlargement,  where  there  was 
an  accumulation  of  serum,  causing  the  cord  to  bulge  out 
laterally."  In  this  case  extensive  changes  were  only  found 
in  the  left  lateral  half  of  the  cord,  but,  inasmuch  as  the  muscular 
disease  was  equally  pronounced  on  both  sides  of  the  body,  the 
essential  lesion,  if  there  be  such,  must  be  sought  in  the  minor 

•  Drummond.  "  On  certain  changes  observed  in  the  spinal  cord  in  a  case  of 
pseudo-hypertrophic  paralysis."    The  Lancet,  Vol.  II.,  1881,  p.  660. 


SPINAL  COED   AND  MEDULLA   OBLONGATA.  lOll 

alterations  of  the  right  and  not  in  the  major  alterations  of  the 
left  half  of  the  cord.  In  1880,  Dr.  Milner  Moore,i  of  Coventry, 
described  three  cases  of  pseudo-hypertrophic  paralysis,  which 
had  occurred  in  a  family  of  seven  children.  The  eldest  of  those 
affected,  a  boy  aged  fifteen  years,  died  subsequently,  and  the 
spinal  cord  was  sent  to  Dr.  Byrom  BramwelP  for  examination. 
Dr.  Bramwell  discovered  "  a  curious  alteration  in  the  shape  of 
the  right  lateral  half  of  the  cord,  and  in  the  arrangement  of  its 
grey  matter,  which  reached  its  highest  development  in  the 
middle  of  the  cervical  enlargement."  This  deformity  was, 
however,  limited  to  one  lateral  half  of  the  cord ;  it  was  evi- 
dently congenital,  and  cannot  be  regarded  as  an  essential  part 
of  the  morbid  anatomy  of  pseudo-hypertrophic  paralysis.  The 
other  changes  described  are  "  collections  of  leucocytes  and  patches 
of  inflammatory  softening  around  the  blood-vessels,"  chiefly 
distributed  throughout  the  grey  matter  in  the  cervical  region. 
But  if  these  collections  of  leucocytes  are  to  be  regarded  as  evi- 
dence of  any  disease,  they  must  be  looked  upon  as  indicating  a 
more  or  less  acute  process,  and  cannot  certainly  be  regarded  as 
evidence  of  a  chronic  and  progressive  process  extending,  as  in 
this  case,  over  a  period  of  at  least  eight  years.  A  case  of  pseudo- 
hypertrophic paralysis  has  also  been  described  by  Pekelharing,^ 
in  which  changes  were  found  in  the  spinal  cord  more  or  less 
similar  to  those  described  by  Drs.  Lockhart  Clarke  and  Gowers, 
and  through  the  kindness  of  my  colleague.  Dr.  Leech,  I  had 
myself  the  opportunity  of  examining  the  spinal  cord  of  a  boy 
that  died  in  the  advanced  stage  of  the  disease. 

Case  VIII. — R.  J ,  aged  seven,  came  under  Dr.  Leech's  care  at  the 

Manchester  Infirmary  on  the  20th  of  September,  1877,  with  the  well-known 
symptoms  of  pseudo-hypertrophic  paralysis.  His  walk  and  method  of  rising 
from  the  recumbent  posture  were  quite  characteristic,  and  lordosis  was  well 
marked.  The  calves  of  the  legs  were  unduly  large  and  firm,  the  arms  and 
thighs  thin,  distinctly  atrophied,  the  other  parts  of  the  body  were  badly 
nourished  though  not  definitely  wasted.  The  pectoral  muscles  were  the 
most  reduced  in  size  and  strength,  whilst  the  deltoids  were  firm  and  large 
as  compared  with  the  other  muscles  of  the  shoulder  and  arm. 

'  Moore  (Milner).  "  Report  of  the  history  of  a  family,  three  members  of  which 
are  the  subjects  of  pseudo-hypertrophic  paralysis."  The  Lancet,  Vol.  I.,  1880,  p.  949. 

*  Bramwell  (Byrom).    Diseases  of  the  spinal  cord.    E din.,  1882. 

^  Pekelharing.  "Ein  Fall  von  Eiickenmarkserkrankung  bet  Pseudomuskel- 
atrophic."    Virchow's  Arch.,  Bd.  LXXXIX.,  1882,  p.  228. 


1012  SYSTEM  DISEASES  OF  THE 

The  boy  could  stand,  though  not  without  difficulty,  for  the  heels  could 
only  be  brought  to  the  ground  with  effi^rt ;  his  power  of  locomotion  was  of 
course  limited,  yet  he  could  easily  walk  across  a  wide  ward  without  falling. 
The  boy  had  appeared  quite  healthy  till  he  began  to  walk.  When  two  years 
old  it  was  noticed  that  he  was  not  so  firm  on  his  legs  as  his  brothers  and 
sisters  had  been.  As  he  advanced  in  age  muscular  weakness  became  more 
apparent.  He  feU  constantly  and  had  difficulty  in  rising ;  he  could  only 
get  upstairs  with  the  aid  of  his  arms.  At  three  years  of  age  the  boy's 
limbs  had  lost  their  plumpness.  The  increase  in  the  size  of  the  calves  of 
the  legs  was  not  noticed  till  sis  months  before  he  came  into  the  infirmary. 
It  does  not  appear  that  any  other  member  of  the  family  had  been  similarly 
affected. 

The  boy  continued  under  my  care  two  years,  and  then  died  of  bronchitis. 
A  slight  amount  of  wasting  went  on  in  all  parts  of  the  body  during  this 
time,  and  the  loss  of  muscular  power  was  considerable. 

Eighteen  months  before  he  died  he  became  unable  to  walk  or  stand,  and 
the  rest  of  his  life  was  passed  in  a  chair  or  lying  down.  For  the  last  six 
months  he  was  unable  to  extend  fully  his  legs,  and  sat  in  a  bowed  position 
owing  to  the  weakness  of  the  muscles  of  his  back.  The  calves  of  his  legs 
decreased  slightly  in  size,  but  continued  large  as  compared  with  the  other 
parts  of  the  body. 

A  post-mortem  was  made  thirty-six  hours  after  death.  The  muscles 
had,  for  the  most  part,  lost  their  normal  appearance,  and  were  of  a  light 
yellovrish  brown  colour.  In  some  places  it  was  difficult  to  distinguish  them 
from  connective  tissue.  This  was  specially  the  case  with  the  pectoral 
muscles.  The  gastrocnemius  looked  on  section  like  dark-coloured  fatty 
tissue.  In  taking  out  the  spinal  cord  a  very  distinct  difference  was 
noticed  between  the  condition  of  the  erector  spinse  in  the  lumbar  and 
upper  dorsal  region.  In  the  former  the  muscles  had  a  connective-tissue- 
like appearance  ;  towards  the  mid-dorsal  region  they  became  darker  and 
redder,  and  in  the  upper  dorsal  region  had  the  ordinary  appearance  of 
muscular  tissue. 

The  muscles  in  the  cervical  region  had  the  same  appearance  as  those  in 
the  upper  dorsal.  The  rhomboids,  levator  anguli  scapula3,  and  trapezius 
were  distinctly  altered  in  colour  and  texture,  the  upper  part  of  the  trape- 
zius being  the  least  affected. 

The  microscope  seemed  to  show  that  nearly  all  the  muscular  tissue  in 
the  body  was  affected,  for  even  in  that  taken  from  the  upper  dorsal  region 
which  looked  healthy  a  distinct  increase  of  connective  tissue  between  the 
fibres  was  evident. 

In  the  muscles  which  appeared  to  the  naked  eye  most  changed,  such 
as  the  pectorals,  the  new  connective  tissue  growth  was  very  much  more 
extensive,  all  the  fibres  of  the  primitive  fasciculi  being  separated  by  it, 
whilst  here  and  there  single  fibres  ran  alone  widely  separated  by  connective 
tissue  from  their  companions. 

Here  and  there  rows  of  fat  cells  appeared  sometimes  between  muscular 


SPINAL   CORD  AND  MEDULLA  OBLONGATA. 


1013 


fibres,  sometimes  smroimded  by  connective  tissue,  and  in  places  accumu- 
lations of  fat  cells  were  met  with  instead  of  single  rows. 

In  the  gastrocnemius  muscle  the  same  condition  was  present,  but  the 
fat  cells  were  much  more  abundant  and  formed  loose  accumulations  of 
adijDose  tissue  amid  the  muscular  fibres  and  connective  tissue. 

In  aU  the  muscles  the  fibres  were  distinctly  narrowed,  and  the  nuclei  of 
the  sarcolemma  were  greatly  increased  in  number,  but  the  striation  of  the 
fibres  was  for  the  most  part  not  interfered  with,  and  was  often  unusually 
distinct,  even  in  fibres  which  had  undergone  a  high  degree  of  atrophy 
{Fig.  206,  c,  d).  The  annexed  diagram  {Fig.  206)  represents  the  more 
usual  appearances  presented  by  the  altered  muscular  fibres. 

In  very  few  of  the  fibres  was  granular  change  met  with,  whilst  hardly 
any  good  examples  of  true  fatty  change  were  seen. 

The  decrease  in  the  diameter  of  the  muscular  fibre  seemed  most 

Fig.  206. 


Fig.  206  (Young).  Muscular  Fibres  in  various  stages  of  degeneratioii,  from  a  case  of 
Pseudo-hypertrophic  Paralysis,— a,  Muscular  fibre  only  slightly  changed,  show- 
ing increase  of  the  muscle  corpuscles,  and  indistinctness  of  the  transverse 
striation  in  certain  parts  of  its  length ;  6,  the  same  as  a,  but  more  atrophied  ; 
c,  muscular  fibre  greatly  atrophied,  and  presenting  nuclei  at  intervals  ;  d,  atro- 
phied muscular  fibre,  with  its  transverse  striation  unusually  distinct ;  e,  atrophied 
fibre  surrounded  by  a  fibrillated  connective  tissue  rich  in  nuclei ;  /and  g,  mus- 
cular fibres  from  the  erector  spinse,  which  manifested  the  greatest  changes  to 
the  naked  eye.  These  fibres  appear  to  have  undergone  a  hyaline  change,  but 
their  transverse  striation  is  still  faintly  visible.  The  fibres  often  tapered  to  a 
point,  sometimes  at  one  and  sometimes  at  both  ends. 


1014 


SYSTEM  DISEASES  OP  THE 


marked  in  the  muscles  which  were  most  changed  to  the  naked  eye.  In 
the  erector  spinse  from  the  upper  dorsal  region,  for  example,  it  was  hardly 
manifest ;  whilst  many  of  the  fibres  of  the  pectoral  muscle  were  reduced  to 
one-sixth  of  their  normal  diameter.  The  narrowing  of  the  muscular  fibres 
seemed  indeed  proportionate  to  the  extent  of  the  development  of  the  new 
connective  tissue. 

Dr.  Leech  kindly  sent  the  spinal  cord  to  me  for  examination.  In  the 
limibar  region  the  normal  loose  and  spongy  texture  of  the  central  column 
was  replaced  by  a  somewhat  dense  and  fibrillated  tissue,  in  which  no  trace 
of  ganglion  cells  could  be  found.  The  blood-vessels  were  enlarged,  and 
their  walls  thickened.  In  the  anterior  grey  horns  the  ganglion  cells  had 
completely  disappeared  from  the  median  area,  the  anterior  group,  and  the 
margins  of  all  the  other  groups  {Fig.  207).  The  ganglion  cells  could  be 
distinctly  seen  in  the  internal  group  {Fig.  207,  i),  but  they  were  atrophied, 

Fig.  207. 


Fig.  207  (Young).  Transverse  Section  from  the  lower  half  of  the  Lumbar  Enlarge- 
ment of  the  Spinal  Cord,  from  a  case  of  Pseudo-hypertrophic  Paralysis. — A, 
Anterior  grey  horn ;  P,  Posterior  grey  horn ;  cc,  central  canal ;  i,  internal, 
a,  anterior,  al,  antero-lateral,  pi,  poatero-lateral,  c,  central  group  of  ganglion 
cells  ;  m,  median  area. 

and  only  a  few  of  their  processes  could  be  discovered,  and  the  central 
group  {Ficf.  207,  c)  presented  one  or  two  cells  only  which  were  not  distinctly 
atrophied.  The  central  portions  of  the  antero-lateral  and  postero-lateral 
(Fiff.  207,  al,  pi)  groups,  however,  contained  some  cells  which  appeared  in 
every  respect  normal,  but  others  contained  an  excess  of  pigment,  while  the 
marginal  cells  were  decidedly  atrophied. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA. 


1015 


In  the  dorsal  region  the  central  column  presented  the  same  general 
appearances  as  in  the  lumbar  enlargement.  The  disease  extended  into  the 
anterior  grey  horn  in  the  dorsal  region  chiefly  in  the  area  which  lies 
between  the  antero-lateral  and  postero-lateral  groups  {Fig.  208,  al,  pi) — 
the  medio-lateral  area.  The  ganglion  cells  of  the  postero-lateral  group 
were  atrophied  and  destitute  of  processes  to  a  very  marked  degree.  The 
cells  could  not  be  seen  in  the  anterior  {Fig.  208,  a)  nor  in  the  central  group, 

Fig.  208. 


Fig.  208  (Young).  Transverse  Section  from  the  middle  of  the  Dorsal  Region  of  the 
Spinal  Cord,  from  a  case  of  Pseudo-hypertrophic  Paralysis.— vc,  The  vesicular 
column  of  Clarke.  The  other  letters  indicate  the  same  as  the  correspondino- 
letters  in  Fig.  207.  t-  = 

but  those  of  the  internal  and  antero-lateral  groups  were  distinctly 
visible.  Many  of  the  latter,  however,  contained  an  excess  of  pigment,  and 
appeared  to  have  lost  a  considerable  number  of  their  processes.  The 
cells  of  the  vesicular  column  of  Clarke  appeared  normal  or  only  slightly 
altered. 

In  the  cervical  region  the  central  column  also  presented  the  same 
general  appearances  as  the  other  portions  of  the  cord  just  examined.  In 
the  lower  half  of  the  cervical  enlargement,  however,  the  median  area  of 
the  anterior  horns  contained  beautiful  healthy  cells,  and  it  contrasted 
strongly  in  this  respect  with  the  median  area  in  the  lumbar  enlargement. 
The  internal  group  of  cells  were  also  healthy,  while  healthy  cells  were  seen 
in  the  anterior  group.  The  marginal  cells  of  the  central,  antero-lateral, 
and  postero-lateral  groups  were,  however,  atrophied,  while  many  of  them 


1016 


SYSTEM  DISEASES  OF  THE 


had  disappeared.  In  the  upper  end  of  the  cervical  enlargement  the  central 
and  antero-lateral  groups  appeared  to  have  been  more  diseased  than  any 
other  portion  of  the  anterior  horn  {Fig.  209,  c,  al). 

Fig.  209. 


Fig.  209  (Young).  Transverse  Section  from  the  ui^per  half  of  the  Cervical  Evlargement 
of  the  Spinal  Cord,  from  a  case  of  Pseudo-hypertrophic  Paralysis.  The  letters 
indicate  the  same  as  the  corresponding  letters  in  Fig.  207. 

Glancing  now  at  all  the  cases  which  have  hitherto  been 
reported  in  which  the  spinal  cord  has  been  found  diseased,  it 
will  be  seen  that  the  changes  described  are  by  no  means  well 
marked,  and  that  the  most  pronounced  changes  which  have  been 
observed  are  limited  to  one  lateral  half  of  the  cord,  and  cannot 
therefore  be  the  cause  of  a  muscular  disease  which  is  sym- 
metrically distributed  over  both  sides  of  the  body.  It  must 
also  be  remembered  that  several  undoubted  examples  of  the 
disease  are  recorded  in  which  the  examinations  of  the  spinal  cord 
have  given  purely  negative  results.  A  patient  of  Duchenne's,  who 
died  in  1871  from  an  intercurrent  affection,  while  the  subject 
of  advanced  pseudo-hypertrophic  paralysis,  is  the  first  case  in 
which  the  tissues  were  subjected  to  a  thorough  microscopical  exa- 
mination.   Portions  of  the  spinal  cord  were  forwarded  to  Charcot,^ 

•  Charcot.     "  Note  sur  I'^tat  anatomique  des  muscles  et  de  la  moelle  6pinidre 
dans  un  cas  paralysie  pseudo-hypertrophique."    Arch,  de  physiol.,  1872,  p.  228. 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  1017 

Vulpian,  and  Lockhart  Clarke,  but  these  competent  observers 
failed  to  discover  any  morbid  changes.  Post-mortem  examina- 
tions have  also  been  made  by  Kesteven/  Brieger/  Bay,^  and 
Schultze,*  and  although  slight  changes  have  been  described  as 
having  been  found  in  the  spinal  cord  in  some  of  these  cases,  yet 
the  ganglion  cells  of  the  anterior  horns  were  reported  healthy 
in  all  of  them.  Dr.  Drummond  also  states  that  in  his  case 
"  throughout  the  entire  cord  the  anterior  cervical  cells  appeared 
to  be  numerous  and  normal."  My  thanks  are  due  to  my  friend. 
Dr.  Brown,  of  Burnley,  for  the  notes  of  the  following  case,  which 
possesses  considerable  interest  in  showing  that  the  spinal  cord, 
as  well  as  the  peripheral  nerves  which  supplied  the  most  diseased 
muscles,  was  in  every  respect  normal. 

Case  IX. — W.  T.,  aged  ten,  came  under  Dr.  Brown's  care  in  November, 
1879.  The  patient,  during  infancy,  was,  according  to  the  statement  of  his 
parents,  fat  and  plump,  and  did  not  suffer  unduly  from  dentition  or  from 
any  of  the  usual  infantile  complaints.  At  twelve  months  of  age  he  had  an 
attack  of  inflammation  of  the  lungs,  from  which  he  made  a  good  recovery. 
He  began  to  walk  at  sixteen  months  of  age,  but  it  was  observed  that  his  gait 
was  awkward,  and  that  he  was  more  liable  to  fall  than  other  children.  At 
five  years  of  age  the  parents  observed  that  the  boy's  arms  were  somewhat 
wasted,  and,  soon  afterwards,  the  flabbiness  of  his  thighs  attracted  atten- 
tion ;  but  the  calves  of  his  legs  were  supposed  to  be  particularly  well 
developed  and  strong.  The  awkwardness  observed  in  the  gait  of  the  boy  at 
an  earlier  period  now  became  more  marked,  and  the  difficulty  he  experienced 
in  getting  up  after  a  fall  attracted  special  attention  ;  but  even  at  this  time 
he  could  walk  three  miles  into  the  country,  and  his  condition  had  not  yet 
caused  serious  uneasiness  to  his  parents.  At  six  years  of  age,  however,  the 
wasting  of  his  arms  and  thighs,  and  the  difficulty  of  walking  had  become 
so  apparent,  that  several  medical  men  were  consulted,  and  the  general 
treatment  recommended  consisted  of  cold-water  sponging,  with  subsequent 
strong  rubbing  with  a  dry  towel,  cod  liver  oil,  and  milk  and  lime  water. 
But  this  treatment  did  not  appear  to  retard  the  progress  of  the  disease ; 
the  wasting  of  the  upper  extremities,  body,  and  thighs,  became  more  and 
more  manifest ;  the  prominence  of  the  calves  became  more  pronounced  ; 
and  walking  became  progressively  more  difficult.  The  patient's  father  and 
mother  were  both  healthy,  and  no  special  proclivity  to  any  nervous  disorder 
could  be  discovered  on  either  side.     This  boy  was  the  third  child  of  his 

•Kesteven.    Journal  of  Mental  Science.    Vol.  XVL,  1871,  pp.  42  and  563. 
^  Brieger.    Deutsches  Arch.  f.  klin.  Med.    Bd.  XXII.,  1878,  p.  200. 
'  Bay.    Hospital  Tidende.    1877.    Abstr.  Vir chow's  Jahresb. 
*  Schultze.    Virchow's  Arch.    Bd.  LXXV.,  1879,  p.  482  ;  and  Bd.  XC,  1882, 
p.  208. 


1018  SYSTEM  DISEASES   OF  THE 

parents.  One  brother  died  at  fourteen  montiis  of  age  from  inflammation  of 
tiie  lungs ;  another  brother  and  three  sisters  are  living,  and  all  are  strong 
and  healthy.  The  father  of  the  patient  was  a  clerk  in  a  manufactory ;  he 
was  in  comparatively  easy  circumstances,  and  the  boy  had  been  well  fed 
and  clothed,  and  had  never  been  exposed  to  cold  or  damp,  or  to  any  parti- 
cular hardship.  The  patient  was  of  moderate  intellectual  capacity ;  but 
although  he  could  read  and  write  a  little,  his  education  was  neglected  for 
the  last  three  years. 

When  first  seen  by  Dr.  Brown  the  patient  was  an  intelligent-looking 
boy,  with  cheerful  expression  of  face  and  fair  complexion.  His  face  was 
round  and  plump,  but  there  did  not  appear  to  be  an  unusual  prominence 
of  any  of  the  facial  or  masticatory  muscles.  The  muscles  of  the  neck,  the 
scapular  muscles,  and  the  serratus  magnus  on  both  sides  were  developed  in 
proportion  to  the  rest  of  the  body,  but  the  latissimus  dorsi  and  the 
pectoral  muscles,  especially  the  sternal  portions  of  the  latter,  were  much 
wasted.  The  deltoids  on  both  sides  appeared  prominent,  probably  less 
from  an  absolute  increase  in  their  size,  than  from  the  great  wasting  which 
all  the  muscles  of  the  arms  had  undergone.  The  muscles  of  the  forearms 
and  hands  were  not  specially  affected.  The  erector  spinas  muscles  were  of 
fair  volume,  but  the  gluteal  muscles  were  prominent,  and  felt  doughy  to 
touch.  The  thighs  were  comparatively  slender,  but  the  calves  were  promi- 
nent, and  the  muscles  felt  inelastic  and  indurated,  and  became  specially 
dense  and  hard  when  contracted.  Each  arm  measured  6^  inches,  the 
forearm  6  inches,  thigh  10|  inches,  and  the  calf  10  inches.  The  feet  were 
maintained  in  the  position  of  talipes  equino-varus ;  the  toes  were  inverted 
and  over-extended  at  the  metatarso-phalangeal,  and  flexed  at  the  phalan- 
geal articulations. 

The  patient  was  unable  to  rise  from  the  ground  without  assistance. 
When  unaided,  he  could  only  get  on  his  hands  and  knees,  and  even  when 
he  could  place  both  hands  on  a  chair  he  could  only  raise  his  body  into  a 
semi-erect  attitude,  and  so  far  as  to  enable  him  to  plant  one  foot  upon  the 
ground.  When  assisted  to  the  erect  posture  he  could  stand  and  walk 
without  extraneous  support.  On  standing,  the  shoulders  were  thrown  well 
back,  so  that  a  plmnb  line,  let  fall  from  the  most  prominent  vertebrae, 
cleared  the  sacrum ;  the  abdomen  was  protuberant,  and  the  vertebral 
column  was  arched,  so  that  a  deep  concavity  was  presented  by  it  in  the 
lumbar  and  lower  dorsal  regions  ;  his  feet  were  kept  widely  apart,  and  the 
heels  could  not  be  brought  to  the  ground,  so  that  the  patient  had  to  balance 
himself  on  his  toes,  which  were  well  tiu-ned  inwards.  On  walking,  the  body 
was  alternately  balanced  on  either  leg,  so  that  the  gait  was  waddling.  The 
patellar-tendon  reactions  were  absent,  but  the  cutaneous  reflexes  were 
normal.  All  the  muscles  reacted  to  the  faradic  current;  there  were  no 
sensory  disorders.  The  general  health  was  good,  and  the  other  organs  of 
the  body  did  not  present  any  feature  worthy  of  being  recorded. 

In  the  autumn  of  1880  I  had  an  opportunity  of  seeing  the  patient 
along  with  Dr.  Brown.     He  was  sitting  on  a  bench,  his  body  being  propped 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  1019 

up,  between  the  wall  and  a  table,  on  the  latter  of  which  he  leaned  heavily, 
supporting  himself  with  his  elbows.  The  vertebral  column  was  now 
arched  forwards,  the  convexity  being  directed  backwards.  He  was  quite 
unable  to  stand,  and  on  an  attempt  being  made  to  place  him  in  the  erect 
posture,  his  legs  doubled  up  under  him  in  a  perfectly  helpless  manner. 
When  he  was  laid  on  his  back  on  a  sofa,  with  his  legs  extended,  he  was 
unable  to  raise  either  heel ;  but  when  placed  on  either  side  he  could  abduct 
the  uppermost  thigh,  and  the  gluteus  medius  could  be  felt  to  contract 
during  this  action  by  the  hand  placed  above  the  trochanter. 

The  boy  was  subsequently  admitted  to  the  Manchester  Eoyal  Infirmary, 
under  the  care  of  Dr.  Leech,  and  was  kept  for  some  time  under  observation, 
but  dxuing  this  period  no  symptom  appeared  requiring  special  description. 
During  his  residence  at  the  Cheadle  Convalescent  Hospital,  where  he  was 
sent  from  the  Infirmary,  both  his  father  and  mother  died  after  a  short  ill- 
ness, and  the  patient  was  subsequently  transferred  to  the  care  of  a  sister, 
living  at  Burnley.  The  j)atient  gradually  became  more  and  more  helpless, 
but  was  able,  almost  to  the  last,  to  sit  in  a  chair,  his  body  being  propped 
up  between  the  back  of  the  chair  and  a  table.  His  face  became  plumper, 
the  temporal  and  masticatory  muscles  being  manifestly  hypertrophied. 
On  April  6th,  1882,  he  was  seized  with  a  severe  attack  of  diarrhoea  and 
vomiting,  accompanied  by  great  prostration,  and  died  from  exhaustion 
early  on  the  morning  of  April  9th. 

Fost-raortem  Examination. — The  post-mortem  examination  was  con- 
ducted by  Drs.  Brown  and  Mackenzie,  and  myself,  thirty-two  hours  after 
death.  The  body  was  placed  vrith  the  face  downwards  soon  after  death, 
and  post-mortem  lividity  was  well  marked  on  the  anterior  surface  of  the 
body.  Post-mortem  rigidity  was  well  pronounced,  and  even  the  wasted 
muscles  of  the  upper  extremities  presented  some  degree  of  rigidity.  The 
most  prominent  part  of  the  calves  of  the  legs  measured,  each,  9j  inches  ; 
the  middle  of  the  thighs,  each,  10|-  inches  ;  the  middle  of  the  upper  arms, 
each,  5f  inches  ;  and  the  thickest  part  of  the  forearms,  each,  5|  inches.  The 
subcutaneoiis  fat  was  \  inch  thick  over  the  calves  of  the  legs,  and  f  inch 
over  the  gluteal  region,  while  there  was  very  httle  subcutaneous  fat  in  the 
lumbar  and  dorsal  regions,  but  it  was  more  abundant  in  the  back  of  the 
neck.  The  gluteal  muscles  were  of  a  pale  yeUow  hue,  with  the  sHghtest 
perceptible  pink  tinge.  The  conversion  of  these  muscles  into  fat  was  so 
complete  that  almost  every  appearance  of  muscular  structure  was  lost. 
The  gastrocnemii  had  more  of  the  pink  tinge  than  the  gluteal  muscles,  and 
also  presented  more  of  the  appearance  of  muscular  structm-e.  The  erector 
spinae  muscles  were  much  wasted,  and  of  a  pale  colovu-,  but  they  were  by  no 
means  so  much  changed  in  appearance  from  healthy  muscles  as  either  the 
gluteal  muscles  or  the  gastrocnemii.  The  scapular  muscles  were  consi- 
derably altered,  the  supraspinators  being  nearly  as  much  changed  as  the 
gluteal  muscles.  The  muscles  of  the  back  of  the  neck  were  wasted,  bat 
presented  almost  the  normal  colour  and  texture  of  muscle.  The  latissimus 
dorsi  mxxscles  were  thin  and  pale,  and  more  like  fibrous  membranes  than 


1020  SYSTEM  DISEASES  OF  THE 

true  muscles.  The  brain  and  spinal  cord  did  not  present  any  abnormal 
appearances  to  the  naked  eye.  The  spinal  cord  was  placed  in  a  two-per- 
cent, solution  of  ammonium  bichromate,  and  reserved  for  microscopical 
examination.  Portions  of  the  diseased  muscles,  and  of  the  sciatic  nerve 
and  of  the  first  cord  of  the  brachial  plexus,  were  also  reserved  for  micro- 
scopical examination.  The  lungs  were  healthy.  The  heart  was  soft  and 
flabby,  and  its  cavities  were  somewhat  dilated.  The  right  side  of  the  heart 
was  full  of  blood,  and  the  left  side  empty.  The  walls  of  the  left  ventricle 
were  one  half  inch  in  thickness  ;  they  were  of  a  pale  yellow  colour,  friable, 
and  easily  torn.  The  walls  of  the  auricles  were  thin,  and  their  external 
smfaces  were  covered  with  a  layer  of  fat.  The  large  intestines,  and  the 
lower  half  of  the  small  intestines  were  distended  with  hard  fsecal  matter. 
A  small  quantity  of  a  purulent  fluid  was  found  in  the  pelvis  of  the  right 
kidney,  but  the  kidneys  were  in  other  respects  normal.  The  liver  presented 
a  normal  appearance. 

A  microscopical  examination  showed  that  every  muscle  of  the  body, 
even  those  which  appeared  almost  normal  to  the  naked  eye,  had  undergone 
extensive  changes.  In  the  muscles  which  were  most  changed,  like  the 
gluteal  muscles,  scarcely  anything  but  fat  cells  and  bundles  of  a  wavy 
fibrous  tissue  could  be  discovered  with  the  microscope.  But  in  those 
muscles  which  were  least  altered  to  the  naked  eye,  as  the  erector  spinse,  the 
fat-cells  were  much  less  abundant,  but  the  muscular  fibres  were  separated 
from  one  another  by  an  interstitial  connective  tissue,  consisting  of  parallel 
fibres,  in  the  midst  of  which  numerous  elongated  nuclei  and  cells  were 
embedded.  The  muscular  fibres  themselves  were  greatly  altered ;  they 
were,  as  a  rule,  atrophied,  some  of  them  being  greatly  reduced  in  size.  The 
nuclei  of  the  sarcolemma  were  much  increased  in  number,  but  the  trans- 
verse striation  remained  well  marked,  even  in  fibres  otherwise  much. 
altered.  The  fibres  themselves  did  not  appear  to  have  undergone  fatty 
degeneration.  A  large  number  of  the  fibres  of  the  cardiac  muscles  were 
atrophied,  and  were  in  many  places  widely  separated  by  interstitial  con- 
nective tissue. 

Nmnerous  sections  from  different  elevations  of  the  spinal  cord  were 
made  by  Mr.  A.  H.  Young,  Pathological  Eegistrar  to  the  Infirmary,  but  no 
evidence  of  disease  can  be  detected  in  them.  Special  attention  was 
directed  to  the  examination  of  sections  from  the  lumbar  enlargement,  the 
dorsal  region,  and  the  cervical  enlargement  on  a  level  with  the  fifth  and 
sixth  cervical  nerves.  No  changes  could  be  detected  in  either  the  sciatic 
nerve  or  first  cord  of  the  brachial  plexus. 

§  449.  Morbid  Physiology. — This  disease  is  so  frequently  asso- 
ciated with  obtuseness  of  the  mental  faculties,  or  with  idiocy  and 
cretinism,  that  Duchenne  was  at  first  inclined  to  believe  that  the 
muscular  changes  resulted  from  cerebral  disease.  More  extended 
observation,  bowever,  soon  sbowed  that  this  afifection  frequently 


SPINAL   CORD  AND  MEDULLA  OBLONGATA.  1021 

exists  independently  of  any  cerebral  lesion.  The  dilatation  of 
the  capillaries  of  the  skin  over  the  affected  muscles,  and  the 
frequent  elevation  of  the  superficial  temperature  of  the  limbs, 
as  compared  with  that  of  the  trunk,  have  led  some  pathologists 
to  think  that  the  primary  lesion  is  situated  in  the  vaso-motor 
nervous  system,  but  no  additional  facts  have  been  discovered 
to  verify  this  supposition.  There  still  remains  the  question, 
whether  the  disease  is  primarily  in  the  muscles,  or  in  that  part 
of  the  nervous  system  which  controls  their  nutrition.  In  the 
first  edition  of  this  work  I  declared  myself  in  favour  of  the 
nervous  theory  of  the  disease,  but  my  examination  of  the 
nervous  tissues  from  the  case  which  has  just  been  reported 
has  convinced  me  that  I  must  abandon  my  former  position. 
In  the  case  of  W.  T.  (Case  IX.)  not  only  was  the  spinal  cord 
normal  throughout  its  whole  extent,  but  I  failed  to  detect  any 
degenerated  fibres  either  in  the  sciatic  nerve  which  supplied 
muscles  in  the  lower  extremities  that  were  deeply  involved  in 
the  disease,  or  in  the  first  cord  of  the  brachial  plexus  which 
supplies  the  deltoid,  biceps,  brachialis  anticus,  and  supinator 
longus,  all  of  which  were  greatly  atrophied.  It  does  not 
appear,  therefore,  that  the  disease  of  the  muscles  in  this  case 
gave  rise  to  a  secondary  ascending  neuritis,  as  Friedreich 
assumes  to  occur  in  progressive  muscular  atrophy  in  order  to 
account  for  the  changes  observed  in  the  spinal  cord  in  that 
disease. 

But  if  pseudo-hypertrophic  paralysis  is  a  primary  muscular 
disease,  it  may  be  asked,  why  describe  it  in  a  work  on  the 
diseases  of  the  nervous  system  ?  My  reply  is  that,  inasmuch 
as  the  locomotive  apparatus  consists  of  a  neuro- muscular 
mechanism,  it  is  not  wise  to  make  a  too  trenchant  division 
between  the  diseases  of  the  regulative  and  of  the  executive 
part  of  this  apparatus.  In  all  our  classifications  so  far,  we 
have,  whenever  a  difficulty  has  arisen,  allowed  practical  require- 
ments to  over-ride  theoretical  considerations;  and  it  must  be 
admitted  by  every  one  that  to  describe  pseudo-hypertrophic 
paralysis  alongside  of  progressive  muscular  atrophy  brings 
with  it  many  practical  advantages.  And  although  we  have 
no  hesitation  in  accepting  the  neuropathic  theory  of  progressive 
muscular  atrophy,  yet  we  are  by  no  means  sure  that  this  theory 


1022  SYSTEM  DISEASES  OF  THE 

is  applicable  to  all  the  cases  which  are  grouped  together  under 
that  name.  The  cases  of  progressive  muscular  atrophy  in  which 
the  spinal  cord  has  been  found  healthy,  such,  for  instance,  as  the 
case  reported  by  Lichtheim,  ought  not  to  be  lightly  passed  over 
in  considering  the  pathology  of  the  affection,  and  it  does  not 
appear  unlikely  to  my  mind  that  two  distinct  diseases  are  at 
present  grouped  in  this  category,  the  disease  in  the  muscles  being 
in  the  one  primary,  and  in  the  other,  secondary  to  an  affection  of 
the  trophic  centres  in  the  spinal  cord.  But  whether  this  be  so 
or  not  it  would  be  impossible  to  have  a  clear  conception  of  the 
differential  diagnosis  of  progressive  muscular  atrophy  without 
describing  side  by  side  with  it  a  disease  like  pseudo-hypertrophic 
paralysis,  which  is  so  much  allied  to  it  clinically,  and  this  alone 
suffices  to  vindicate  the  right  of  the  latter  affection  to  be  con- 
sidered in  this  place. 

§  450.  Prognosis. — In  two  cases  under  the  care  of  Duchenne, 
the  disease  was  arrested  in  its  first  stage  by  treatment,  and  a 
case  has  recently  been  mentioned  by  Dr.  Donkiu,^  at  a  meeting 
of  the  Pathological  Society  of  London,  which  had  completely 
recovered.  This  shows  that  the  prognosis  is  not  absolutely 
hopeless.  When,  however,  the  second  period,  or  that  of  apparent 
hypertrophy  of  the  muscles,  has  set  in,  the  case  is  in  all  proba- 
bility beyond  the  reach  of  treatment,  and  it  is  still  more  surely 
progressive  and  fatal  in  the  period  of  atrophy. 

§  451.  Treatment — Duchenne  relied  mainly  on  the  faradic 
current  in  the  two  cases  which  he  cured.  Baths,  friction,  and 
shampooing  were  also  employed  as  subsidiary  means.  The  gal- 
vanic current  applied  over  the  sympathetic  nerves  has  been 
recommended  by  Benedikt,  but.  this  method  has  not  been  found 
to  possess  any  advantage  in  the  hands  of  others.  An  improve- 
ment in  motor  power  took  place  in  a  case  under  the  care  of 
Rosenthal  by  the  application  of  the  constant  current  several 
times  a  week  to  the  nerves  of  the  hypertrophied  muscles,  along 
with   the   daily   use   of  rubbing   and   the   cold    plunge    bath. 

'  Donkin.  "Note  on  a  case  of  pseudo-hypertrophic  paralysis  (?)  Eecovery." 
The  British  Medical  Journal,  April  loth,  1882. 


SPINAL  CORD  AND   MEDULLA   OBLONGATA.  1023 

Gymnastics  and  mountain  air  aided  the  treatment.  The  iodides 
of  iron  or  of  potassium,  or  when  there  are  cerebral  symptoms  the 
bromide  of  potassium,  may  be  tried  ;  but  the  remedies  which 
promise  to  do  most  good  are  the  so-called  tonics.  Arsenic, 
Parrish's  chemical  food,  phosphorus,  and  cod-liver  oil,  and  in 
some  cases  strychnia  or  nux  vomica,  may  be  tried. 


A.   IRELAND  AND  CO.,   PRIKTERS,   PALL  MALL,   MANCHESTER. 


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